Knowledge and practice of Management Type2 Diabetes ...ijcmsdr.com/Vol-1-Is-4/C-070-2240.pdf · of attending conferences, workshop, seminars, courses about diabetes management during

http://www.ijcmsdr.com 22

International Journal of Current Medical Science and Dental Research

Volume 1 Issue 4 ǁ November-December 2019 ǁ PP 22-40

ISSN: 2581-866X || www.ijcmsdr.com

Knowledge and Practice of Management Type2 Diabetes

Mellitus during Ramadan and Associated Factors among

Family Physicians in the Primary Health Care Centers of the

Ministry of the Health Inside Makkah - Al Mukarramah City

2018

Ghadeer AL-Aidarous 1, Osama Mohammed AL Wafi 2 1Family Medicine Resident, Ministry of Health, Sadui Arabia. 2SBFM, ABFM, MPH, Family Medicine Consultant, Saudi Arabia.

-----------------------------------------------------------------------------------------------------------------

ABSTRACT: Background: Islam permits certain groups of Muslims from not

fasting Ramadan including Muslims with diabetes. However, many

patients insist on participating in Ramadan fasting.

Objectives: To evaluate knowledge and practice of management of

Type 2 Diabetes Mellitus during Ramadan and associated factors

among family physicians in the primary health care centers.

Subjects and methods: Cross-sectional study among family

physicians (specialists and consultants) in primary health care

centers of the Ministry of Health inside Makkah Al- Mukarramah

city. A self-Administered questioner was utilized for data

collection.

Results: The study included 80 primary healthcare physicians. The

guideline mostly followed for management of diabetes during

Ramadan among the participants was ADA, followed by IDF.

Adequate knowledge of basic concepts/management skills, non-insulin dose modification, nutrition plan and insulin

management of type 2 diabetes during Ramadan were observed among 46.2%, 81.2%, 23.7% and 21.2% of the

physicians, respectively with an overall adequate knowledge level of 41.2%. Older physicians (p=0.001), consultants

(p<0.001), physicians who reported having access to the online medical library (p=0.043) and those who had a history

of attending conferences, workshop, seminars, courses about diabetes management during Ramadan (p=0.037) were

more knowledgeable regarding management of type 2 diabetes in Ramadan than others. Overall the percentage of

the safe practice score of management of diabetes during Ramadan ranged between 53.3 and 100%.

Conclusion: Overall, knowledge regarding management of T2DM during Ramadan was unsatisfactory among family

physicians in Makkah. However, their safe practice of management of diabetes during Ramadan was satisfactory.

-----------------------------------------------------------------------------------------------------------------

1. INTRODUCTION

1.1 Background

The population of Muslims is rising steadily across the world. For example, in 2010, the total population of

Muslims was estimated at 1.6 billion representing 23% of the global population. The population of Muslims is

predicted to reach 2.76 billion representing 29.7% of the global population by 2050 (1). Within the Muslim population,

Mnif F, Slama CB (2) demonstrates that it is estimated that around 40 to 50 million individuals with diabetes

worldwide fast during the holy month of Ramadan.

Muslims diagnosed with diabetes fast Ramadan in adherence to the five pillars of Islam of which fasting is the

fourth pillar. Fasting Ramadan implies that a Muslim adult must refrain from drinking and eating from dawn to sunset

every day of this month. The month of Ramadan lasts about 29 to 30 days. During this month, most Muslims eat two

Corresponding Author: Ghadeer AL-Aidarous, Family Medicine Resident, Ministry of Health, Sadui Arabia. How to cite this article: Ghadeer AL-Aidarous , Osama Mohammed AL Wafi, Knowledge and practice of Management Type2 Diabetes Mellitus during Ramadan and Associated Factors among Family Physicians in the Primary Health Care Centers of the Ministry of the Health Inside Makkah- Al Mukarramah City 2018, Int. Jour. Curr. Med. Scie. Dent. Res. 2019; 1(4): 22-40.

Date of Submission: 2019-11-10

Date of Acceptance: 2019-11-27

http://www.ijcmsdr.com/

www.ijcmsdr.com

Ghadeer AL-Aidarous et al.


meals including one begins before sunrise (known as Sohor) and another one comes after sunset (known as Iftar) (3).

There is no restriction on food or fluid intake for Muslims Between sunset and dawn.

However, Islam permits certain groups of Muslims from not fasting Ramadan or part of Ramadan including Muslims

with diabetes and other chronic diseases, sick persons, travelers, and pregnant women as they are exempted from

this Islamic duty.

Many patients insist on participating in Ramadan fasting. For example, Mnif F, Slama CB (2) examines the

extent to which Muslim patients with diabetes fast in 13 Islamic countries. The authors find that 43% of patients with

type-1 diabetes and 79% of patients with type-2 diabetes fast the month of Ramadan. Karamat, Syed (4) argue that

most patients with DM are asymptomatic. Hence, they do not consider themselves as having an illness and fast during

Ramadan. The authors contend that fasting Ramadan for diabetic patients may cause health concerns resulting in

health problems including hypoglycemia, hyperglycemia with or without ketoacidosis, and dehydration. Karamat, Syed

(4) also added that another problem is the reluctance of patients in taking their medications during the fast; therefore

timing and dosage of anti-diabetic agents have to be adjusted for individual patients.

Karamat, Syed (4) provided a review of some empirical studies concerning DM management and guidelines

during Ramadan. They show that eating stimulates the secretion of insulin from the islet cells of the pancreas. This, in

turn, results in glycogenesis and storage of glucose as glycogen in the liver and muscle. On the contrary, the authors

show that during fasting secretion of insulin is reduced while counter-regulatory hormones glucagon and

catecholamines are increased. This leads to glycogenolysis and Gluconeogenesis. Karamat, Syed (4) concluded that the

low levels of insulin in circulation also lead to increased fatty acid release and oxidation that generates ketones which

are used for nutrition by the body.

In their review, Karamat, Syed (4) elaborated that there are several studies have shown no significant change

in glucose concentration in patients with diabetes. However, there is an increased risk of severe hypoglycemia,

hyperglycemia, and ketoacidosis. Mnif F, Slama CB (2) showed an increase in the risk of severe hypoglycemia (defined

as hypoglycemia leading to hospitalization) of around 4.7-fold in patients with type 1 and 7.5- fold in patients with

type 2 diabetes. On the other hand, the authors show that the incidence of severe hyperglycemia (requiring

hospitalization) increased five-fold in patients with type 2 and three-fold in type 1 diabetes. In that note, Irshad, Khan

(5) argued that diabetes mellitus is a complex, chronic illness requiring continuous medical care with multifactorial risk

reduction strategies beyond glycemic control.

The overall evidence shows that Muslim patients with diabetes who fast during Ramadan face challenges in

diabetes management due to substantial alterations in lifestyle and treatment that frequently accompany the decision

to fast. Al Sifri and Rizvi (3) asserted that if Muslim patients with diabetes choose to fast during the holy month, then it

is important to schedule an appointment with the healthcare professional up to three months before Ramadan to

establish diabetes management to control the blood sugar levels during the holy month. Moreover, Zargar(6) argued

that to avoid increasing the risk of acute metabolic complications including hypoglycemia, hyperglycemia, diabetic

ketoacidosis, dehydration, and thrombosis; then it is vital for Muslim patinas with diabetes to commence diabetes

management to control.

Zargar (6) also asserted that what is equally important to start Diabetes management, is the role of

physicians in informing patients' choices to fast or not and also in education and support of those diabetic patients

who choose to observe the Ramadan fast. Beshyah, Farooqi (7) supported the view of Zargar (6) arguing that to

provide effective diabetes management to control diabetic patients.

To date, there is a lack of research in the necessary knowledge of modifying management DM during Ramadan among

physicians in Saudi Arabia. Thus, this proposal aims to fill this research gap by examining the essential knowledge of

managing diabetes during Ramadan among physicians in Saudi Arabia, especially, among family physicians of the

ministry of health in Makkah Al-Mokarramah city.

1.2 Rationale

Because the diabetic patients who fast during Ramadan represent a challenge to their physicians, there is a

need to provide more intensive education before fasting to control blood sugar level adequately and to avoid health

problem including hypoglycemia, hyperglycemia, dehydration, etc.




1.3 Aim of the Study

Evaluation Knowledge and practice of Management Type2 Diabetes Mellitus during Ramadan and Associated

Factors among Family Physicians in the Primary Health Care Centers of the Ministry of the Health inside Makkah- Al

Mukarramah City 2018.

1.4 Objectives

1- To estimate the Knowledge level of management of type 2 Diabetes Mellitus during Ramadan among family

physicians in the PHCC of the MOH inside Makkah Al-Mukarramah city2018.

2- To determine the associated factors that affect Knowledge and practice of management type2Diabetes Mellitus

during Ramadan during the study period in the same place among the same study population.

3- To associate the findings with selected demographic variables

4- To assess the practice of management type2 Diabetes Mellitus during Ramadan among family physicians in the

PHCC.

1.5 Literature Review

In 2017, a cross-sectional Internet-based survey distributes was done among 236 physicians mostly practicing

in UAE, to assess Physicians’ Knowledge, Attitudes, and Practices in Management of Diabetes during Ramadan Fasting

by Beshyah SA et al (2017). They show significant results in terms of management knowledge including more than 90%

recognized the importance of Ramadan-focused education, 75.1% valued the importance of glycemic control at night

time, and 71.2% were aware of the exemption of T1DM. Moreover, the outcomes of Beshyah SA et al (2017)’s study

show that 69.0% of the respondents highlight the familiarity with the time of the highest risk of hypoglycemia, and

62.0% of the respondents identify the rulings regarding exemption of pregnant women with diabetes. However, in

regards to attitude, the study showed that 71% of the study’s sample state that they are fully confident or in the

management of diabetes during Ramadan. The reasons behind this significant level of awareness are that 41% of

respondents followed the ADA workshop of 2005 and its updates. Its risk scale was thought to be the most practical by

34% of respondents. Risk stratification practices were stated to be undertaken consistently, often or occasionally

(80%, 15%, and 5% of respondents respectively). 78% confirmed formal stratification using one of the published

guidelines (7).

Another cross-sectional study by Zainudin SB et al., Published in Singapore Med J (2017) conducted over a

period of three months (June 2011–August 2011) in Singapore among 92 Muslims patients with DM (34 male, 58

female) to examine the level of knowledge regarding DM and the self-management of DM when fasting during

Ramadan. The result showed the mean DM knowledge score was 58.8% for general knowledge and 75.9% for fasting

knowledge. Besides, even though during the previous Ramadan 71.4% of the patients consulted their physicians,

37.3% did not monitor their blood glucose levels, and 47.0% had hypoglycemic episodes. Among those who had

hypoglycemia, 10.8% continued to fast. The study concludes unsafe self-management practices were observed among

DM patients who fasted during Ramadan (8).

There is a published study in BMJ diabetes research and care (2017). Lee JY et al., conducted a qualitative

study in Malaysia among 53 participants with T2DM as a semi-structured focus group interview asked to share their

perspective on Ramadan fasting. Towards fasting, during Ramadan, the participants reported optimism, as they

believed that fasting was beneficial to their overall well-being, and a time for family bonding. Most of them made

limited attempts to discuss with their doctors on the decision to fast and self-adjusted their medication based on

experience and symptoms during this period. They also reported difficulty in managing their diet, due to fear of

hypoglycemia. They Concluded the Collaboration with religious authorities should be explored to ensure patients

receive adequate education before fasting during Ramadan (9).

A prospective study was conducted Interest of the Therapeutic education in patients with type 2 diabetes

observing the fast of Ramadan, by Jamoussi H et al. (2016) in Tunis among 54 type2 diabetic patients(28 men and 26

women) aged36–65 years. Patients divided into two groups: group A(n=26)received an education session one to two

weeks before the month of Ramadan; group B (n= 28) did not have appropriate therapeutic education except

therapeutic adjustments. The result showed the fast completed without complications in 25 diabetic patients

educated group and 22 control patients. Therapeutic education has led to a decline of 0.27% in HbA1c in the educated

group while glycemic control in diabetic patients uneducated remained stable (10).




A Study conducted and published in the journal of fasting and health by Hassanein MM et al. (2016). The

authors survey the Knowledge and Attitude of Physicians toward the Management of Diabetes Mellitus during

Ramadan. Among 905 participants including 36.7% of whom (n=333) were primary care physicians, 29.4% (n=267)

were members of a secondary care setup, and 22.5% (n=204) recruited in private institutions, and 11.5% (n=104) had

an unspecified workplace. This study concludes that the participants assured the awareness of Ramadan-focused

educational programs is offered among 63.8% (n=397) for their patients. Based on the results of this study, 95% of the

physicians (n=862) believed the type of diabetes to be “important” or “very Important” indecision-making for

Ramadan fasting. Furthermore,

In regards to diabetes’s control before Ramadan, the results s how that this control classified as “important”

or “very important” by 95% of the physicians (n=848). An additional distinguished result this study highlights is that

the majority of respondents emphasized on the critical role of self-monitoring of blood glucose in the management of

patients receiving insulin or sulphonylureas (SUs), and to a lesser extent in cases treated with other verbalized

hypoglycemic agents than SUs (11).

To assess physicians` awareness in Diabetes management during Ramadan, AlSlail, Fy (2015) conducted a

qualitative study based on using two focus group discussions in primary health care center (PHCC) doctors who

manage diabetic patients in the Riyadh region. Each group included 12 participants who were physicians working in

PHCCs and categorized by gender; 12 males and 12 females selected from 12 PHCCs by choosing one male and one

female from each center. The two groups were the physician age range was 30–57 years and their clinical experience

varied from 6–28 years. The results of the study show that there is a lack of knowledge of the classification system for

risk assessment of diabetic patients who fast during Ramadan. Moreover, all the responses demonstrate that

there were misconceptions regarding nitroglycerin tablets placed under the tongue to nullify fasting. The results also

highlight other issues that have been addressed by respondents such as first how to adjust the dose and subsequently

convince the patient to follow a new regimen. The second and the third issues are the loss of patient follow-up due to

referral to the hospital, the refusal of some laboratories to perform examinations for patients referred from other

PHCCs respectively. The last issue that has been addressed by the responses is that lack of patient medication

compliance (12).

A cross-sectional descriptive study performed to estimate Diabetes patient management by pharmacists

during Ramadan by Wilbur K et al. (2012), among a convenience sample of 580 Qatar pharmacists. One-third of

pharmacists reported at least weekly interaction with diabetes patients during Ramadan. The result showed internet

(94, 53%) was the most popular resources for management advice and (80, 45%) the practice guidelines; however,

only twenty percent were aware and had read the American Diabetes Association Ramadan consensus document. The

knowledge scores of Pharmacist appropriate care was overall fair (99, 57%).in conclusion, Educational programs are

necessary to improve pharmacist knowledge in the provision of accurate patient advice (13).

2. METHODOLOGY

2.1 Study Design Cross-sectional study

2.2 Study Population

Family physicians working in primary health care centers of the Ministry of Health inside

Makkah Al-Mukarramah city. They included 100 males and females.

INCLUSION CRITERIA

• Consultant and specialist Family physicians working in the primary health care centers of the ministry of health

inside Makkah Al-Mukarramah at the time of the study were invited to participate in the study.

• Both males and females.

• All nationalities. 2.3 Study Area

It is the heart of the Islamic world, the cradle of revelation and the most sacred land on the earth. Islamic

civilization and the mission of the Prophet Mohammad (peace be upon him), have started from its high mountains.

Makkah is the home of science and varied cultures. For several years to this day, it receives and welcomes millions of




visitors from all over the globe. The mosque that surrounds the Ka'aba, the Masjid Al-Haram, is the largest in the

world and is every year the destination of millions of pilgrims from all around the world. There is four inner and three

outer sections of primary health care, and there are One hundred of Family physicians working in PHCC of the MOH

inside Makkah Al-Mukarramah city.

2.4 Sample Size The sample size is 80 family physicians. This calculation was done by using Raosoft website, based on 50%

prevalence, 95% confidence level, 5% error.

2.5 Sampling Technique

Simple random sampling technique was used initially; a list of family physicians in the PHCC of the Ministry of

Health inside Makkah Al-Mukarramah was prepared with code numbers. After that selected the sample from the list

by using the random number generator was done. Accordingly, the questionnaire was distributed among exclusive

doctors’ names.

2.6 Data Collection Tool Self-administered questioners were distributed to all directors of the primary health care centers according

to the family physicians list involved in the study. The survey has been previously used in a similar study carried out in

Qatar (13). The researcher reconstructed it with some modifications. The questionnaire consists of 3 domains:

- Socio-demographic: Gender, age, nationality, the medical degree.

- Knowledge of appropriate patient care during Ramadan fasting:

It is composed of ten knowledge questions. A score of “1” was given to right answers and a score of zero was

given to wrong answers. Total score was computed for each participant. It ranged between 0 and 20. The

percentage of the total score was estimated physicians who scored below 60% were considered having “inadequate

knowledge” whereas those scored at or above 60% were considered having “adequate knowledge”.

- Diabetes patient care experiences: It is composed of 9 statements with 5-Likert scale ranged between

strongly agree (score of 5) to strongly disagree (score of 1). These statements were scored in the way that the highest

the score the more safe the practice in management of diabetes during Ramadan, Total score was computed (9-45)

and its percentage was estimated, tested for normality and used of comparisons.

2.7 Reliability &Validity The researcher tested the reliability by retesting 10% of participants to compare the answers. An average

correlation coefficient of 0.8 was obtained, and the validity was ascertained by two consultant experts in the field.

2.8 Data Collection Technique

The researcher distributed the questionnaires to directors of the PHCC who redistributed them to

participants at their PHCC during a three week period. Each week the surveys was spread to the Family physicians in

the PHCC of the Ministry of Health inside Makkah Al-Mukarramah at the beginning of the week and collected at the

end of the week.

2.9 Study Variables

DEPENDENT VARIABLES: Knowledge of DM management during Ramadan among family physicians of the

Ministry of Health inside Makkah Al-Mukarramah city.

INDEPENDENT VARIABLES:

- Age

- Gender

- Nationality

- Medical degree

- The number of family physicians in the primary care center.




2.10 Data Entry and Analysis

The Statistical Package for Social Sciences (SPSS) software version 25 was used for data entry and analysis.

Descriptive statistics (e.g., number, percentage, mean and standard deviation) and analytic statistics using Chi-Square

tests (χ2) to test for the association and the difference between two categorical variables were applied. Since age and

duration spent by physicians in reading about diabetes were abnormally distributed as evidenced by significant

Shapiro-Wilk test, p<0.001, they were described using median and interquartile range (IQR) and analysed using Mann-

Whitney non-parametric statistical test to compare between two different groups. A p-value equal to or less than 0.05

was consider statistically significant.

2.11 Pilot Study/Pretesting

The pilot study was conducted on 10% of sample size, which is approximately eight of family physicians

similarity to the target group using the same questionnaire in Jeddah. The deficit was identified and modified

according to the result. The data from the pilot study were analyzed and were not included in this study.

2.12 Ethical Considerations:

• Approval from the Directorate of Health Affairs of the Holy Capital Primary Health Care was obtained.

• Approval from institutional review board.

• All information was kept confidential and results will be submitted to the department as feedback.

2.13. Budget, Fund or Grant:

Self-funded

3. RESULTS

Personal characteristics The study included 80 primary healthcare physicians with 100% response rate. Their age ranged between 27

and 47 years (33.9±5.5 years). More than half of them (53.7%) were females. Majority of them were Saudis (96.3%)

and married (80%). More than half of them (51.3%) were specialists. Nearly two-thirds (67.5%) were trainer in Family

Medicine program. The participants spent on the average between 0 and 19 hours per week in reading about diabetes

with a median of 2 hours.

Table 1: Personal characteristics of the participants (n=80)

Frequency Percentage

Gender

Male 37 46.3

Female 43 53.7

Age (years)

Range 27-47

Mean±SD 33.9±5.5

Nationality

Saudi 77 96.3

Non-Saudi 3 3.7

Marital status

Single 15 18.8

Married 64 80.0

Widowed 1 1.2

Current professional grade

Specialist 41 51.3

Consultant 39 48.7

Trainer in Family Medicine

program

No 26 32.5

Yes 54 67.5

Duration (hours per week) spent by

physicians in reading about

diabetes

Range 0-19

Mean±SD 2.7±2.8

Median 2




Diabetes educational history The guideline mostly followed for management of diabetes during Ramadan among the participants was ADA

(63.8%), followed by IDF (28.8%). Figure 1

History of having access to the online medical library was reported by 41.2% of the participants as displayed in Figure

2. Among them, the commonest was Up To Date (42.6%), followed by BMJ (21.3%) and Best practice (17%). Figure 3

Less than half of the participants (43.7%) have attended conferences, workshop, seminars, and courses about diabetes

management during Ramadan during the past year academic as seen in Figure 4.

Figure1: Guideline mostly followed for management of diabetes during Ramadan among the participants

Figure 2: History of having access to the online medical library among the participants

Figure 3: Online medical library accessed by the participants (n=33)

Others BMJ

Up To Date Dynamed Best

ptractice

17

45

40

35

30

25

20

15

10

5

0

12.

8

14.

9

21.

3

42.6

3,

3.8%

51,

63.8%

23,

28.8%

ADA

AACE/A

CE IDF

Others

3,

3.8%




Figure 4: History of attending conferences, workshop, seminars, and courses about diabetes management during

Ramadan during the past year academic among the Participants` clinical experience Half of the participants had 5 years of experience or less whereas 12.5% had more than 10 years of experience in

the current practice as illustrated in figure 5. More than one-third of the participants (37.5%) have seen less than 10 diabetic patients on the average per clinic

whereas 27.5% have seen 15 patients or more. Figure 6 Almost two-thirds of the participants (62.5%) work in a CBAHI accredited primary healthcare center as shown in

Figure7.

Figure 5: Experience of the participants in the current practice (years)

Figure 6: Average number of diabetic patients managed per clinic




Figure 7: History of working in a CBAHI accredited primary healthcare center.

History of diabetes As demonstrated in Figure 8, only four physicians (5%) had history of diabetes.

Figure 8: History of diabetes among the participants

Knowledge of management type2 Diabetes Mellitus during Ramadan -Basic concepts and management skills:

The majority of the participants (92.5%) knew that diabetic patients whose blood glucose level was <70 mg/dl should break their fast while only 57.5% know that those whose blood glucose level was >300 mg/dl should break their fast. Only a quarter of them could recognize the frequency of advised self-monitoring of blood glucose (SMBG) in high risk patient according to IDF. Table 2

Adequate knowledge of basic concepts and management skills regarding type 2 diabetes management during Ramadan was observed among 46.2% of the physicians. Figure 9 -Non-insulin dose modification Majority of the participants (90%) knew the preferred time to take once daily dosing, during Ramadan. Also, majority of them (95%) know that Daily dose of met for min remain sun changed during Ramadan. However, only 46.3% and 31.3% knew that the dosage of Thiazolidinedione and A carbose should remain unchanged during Ramadan. Table 2 Nutrition plan

Almost half of the participants (48.8%) knew that plenty of water should be of start atIftar in Ramadan while only 15% knew that protein and fat should be consumed in adequate amount at Suhoor. Table2 Adequate knowledge regarding nutrition plan during Ramadan was observed among 23.7% of the physicians. Figure 9




-Insulin management:

Almost two-thirds of the physicians (62.5%) knew the frequency of performing the blood glucose self-measuring (BSM) by patients and make the titration and adjustments of the dose accordingly. Regarding insulin dose modifications for patients with T2DM during Ramadan, 60% knew that premixed insulin BID should be taken as usual morning dose at iftar and reduce evening dose by 25–50% and take at suhoor while only 30% knew that for premix edinsulinOD, they should taken or maldoseatiftar. The adequate knowledge regarding insulin management during Ramadan was observed among 21.2% of the physicians as seen in Figure9.

Overall, 41.2% of the participated physicians had adequate knowledge (>60%) regarding management type2 Diabetes Mellitus during Ramadan as illustrated in Figure 10.

Table 2: Response of the participants to knowledge questions regarding management type2 Diabetes Mellitus during Ramadan

Right answer

NO. %

Basic concepts and management skills

How often self-monitoring of blood glucose (SMBG) is advised to be done in high risk patient according to IDF? (6-7 times per day)

20 25.0

Who should break their fast?

(Blood glucose<70 mg/d) 74 92.5

(Blood glucose glucose>300 mg/d) 46 57.5

About exercise in diabetic patient during Ramadan, patient is advised to: (Maintained the normal levels of physical activity

49 61.3

Non-insulin dose modification

If the patient is taking once daily dosing, what is the preferred time to take it during Ramadan? (At iftar)

72 90.0

How to modify metformin? (Daily dose remains unchanged) 76 95.0

How to modify BID Sulfonylurea? (Iftar dose remain sun-Changed and Suhoordose

should be reduced inpatient with good glycemic control)

71 88.8

The medication that should remain un-changed (in the

dose) during Ramadan

Metformin (√) 76 95.0

Thiazolidinedione (√) 37 46.3

Acarbose (√) 25 31.3

DPP-4 inhibitors (√) 70 87.5

Nutrition plan

The total daily intake of carbohydrate, protein and fat should be: (45–50% carbs 20–30% protein and 35% fat of total caloric intake) 24 30.0

Which of the following nutrient content should be consumed in adequate amount at Suhoor? (Protein and fat) 12 15.0

Which of the following nutrient content should be of start atIftar in Ramadan? (Plenty of water) 43 39 48.8




Insulin management

How frequently (by days) the patient should perform the blood glucose self-measuring (BSM) and make the titration and adjustments of the dose accordingly? (Every 3 days)

50 62.5

Insulin dose modifications for patients with T2DMduring

Ramadan

-Take at iftar and Reduce dose by 15–30% (basal insulin 45 56.3

OD)

-Take normal dose at iftar. Omit lunch- me dose. Reduce 41 51.2

suhoor dose by 25–50% (basal insulin BID/bolus insulin))

-Take usual morning dose at iftar. Reduce evening dose by 48 60.0

25–50% and take at suhoor (Premixed insulin BID)

-Take normal dose at iftar (Premixed insulin OD) 24 30.0

-Omit afternoon dose. Adjust iiftar and suhoor doses 33 41.3

(Premixed insulin TID)

Figure 9: Physicians` knowledge regarding different aspects of type 2 diabetes management

during Ramadan

Figure 10: Overall Knowledge of the physicians regarding type 2 diabetes management during Ramadan.

Factors associated with knowledge

-Socio-demographic factors




Table 3 summarizes the factors associated with knowledge regarding the management of Type2 Diabetes Mellitus during Ramadan among the participants. The age of physicians who had adequate knowledge was significantly higher than that of those with inadequate knowledge (median values were 35 and 32 years, respectively), p=0.001. Almost two-thirds of consultants (61.5%) versus 22% of specialists had adequate knowledge, p<0.001. Other factors (gender, nationality, marital status, and training in Family Medicine program and experience in the current place) were not significantly associated with knowledge regarding management of type 2 diabetes in Ramadan.

Table 3: Socio-demographic factors associated with knowledge of management of Type2 Diabetes Mellitus during Ramadan among family physicians, primary health care centers, Ministry of the Health, Makkah- Al Mukarramah

city Knowledge level p-value

Inadequate N=47 N(%)

Adequate N=33 N(%)

Gender Male (n=37) Female (n=43)

21 (56.8) 26 (60.5)

16 (43.2) 17 (39.5)

0.737* Age (years) Median IQR Mean rank

32

30-35 33.33

35

34-39.5 50.71

0.001‡

Nationality Saudi (n=77) Non-Saudi (n=3)

45 (58.4) 2 (66.7)

32 (41.6) 1 (33.3)

0.632**

Marital status Single (n=15) Ever married (n=65)

10 (66.7) 37 (56.9)

5 (33.3)

28 (43.1)

0.490* Current professional grade Specialist (n=41) Consultant (n=39)

32 (78.0) 15 (38.5)

9 (22.0)

24 (61.5)

<0.001*

Trainer in Family Medicine program No (n=26) Yes (n=54)

15 (57.7) 32 (59.3)

11 (42.3) 22 (40.7)

0.894*

Duration (hours per week) spent by physicians in reading about diabetes Median IQR Mean rank

2 1-4

40.49

2 1-3.5 40.52

0.996‡

Experience in the current practice (years) ≤5 (n=40) 6-10 (n=30) >10 (n=10)

26 (65.0) 17 (56.7) 4 (40.0)

14 (35.0) 13 (43.3) 6 (60.0)

0.341*

* Chi-square test ** Fischer Exact test‡Mann-Whitney test

Professional and work-related factors

Physicians who reported having access to the online medical library were more knowledgeable than those without such history as adequate knowledge was reported among 54.5% and 31.9% of them, respectively (p=0.043). Similarly, more than half of physicians who had a history of attending conferences, workshop, seminars, courses about diabetes management during Ramadan during the past academic year compared to 31.1% of those without such history had adequate knowledge, p=0.037. Other studied factors (guideline mostly followed for management of diabetes during Ramadan, average number of diabetic patients managed per clinic, history of diabetes among the participants, and history of working in a CBAHI accredited primary healthcare center) were not significantly associated with knowledge regarding management of type 2 diabetes inRamadan.




Table 4: Professional and work-related factors associated with knowledge of management of Type2 Diabetes Mellitus during Ramadan among family physicians, primary health care centers, Ministry of the Health, Makkah- Al

Mukarramah city

Knowledge level p-value

Inadequate N=29 N(%)

Adequate N=51 N (%)

History of having access to the online medical library among the participants Yes (n=33) No (n=47)

15 (45.5) 32 (68.1)

18 (54.5) 15 (31.9)

0.043

History of attending conferences, workshop, seminars, courses about diabetes management during Ramadan during the past academic year among the participants Yes (n=35) No (n=45)

16 (45.7) 31 (68.9)

19 (54.3) 14 (31.1)

0.037*

Guideline mostly followed for management of diabetes during Ramadan among the participants ADA (n=51) AACE/ACE (n=3) IDF (n=23) Others (n=3)

32(2.7) 1(33.3)

13 (56.5) 1 (33.3)

19 (37.3) 2 (66.7)

10 (43.5) 2 (66.7)

0.576*

Average number of diabetic patients managed per clinic <10 (n=30) 10-14 (n=28) ≥15 (n=22)

19 (63.3) 17 (60.7) 11 (50.0)

11 (36.7) 11 (39.3) 11 (50.0)

0.607*

History of diabetes among the participants No(n=76) Yes(n=4)

43 (56.6) 4 (100)

33 (43.4)

0 (0.0)

0.113**

History of working in a CBAHI accredited primary healthcare center

No (n=30)

Yes (n=50)

14 (46.7)

33 (66.0)

16 (53.3)

17 (34.0)

0.089*

*Chi-squaretest ** Fischer Exact test

Safe practices and management of Diabetes during Ramadan

Table 5 shows that majority of the participants either strongly agreed or agreed that detailed history, educate the patients the fluid and meal planning and educate the patients the medication adjustments during fasting (98.7%), patient's experience during previous Ramadan (97.5%), educate the patients when to exercise (96.2%), educate the patients when to break the fast and the role of SMBG (93.7%), patient's ability to self-manage diabetes (94.9%) and educate the patients the risk quantification (91.1%) are safe practices in management of diabetes duringRamadan. Overall the percentage of the safe practice scoreof management of diabetes during Ramadan ranged between 53.3 and 100% with a mean±SD of 92.5±10.3% and median (IQR) of 95.6 (91.1-100%). Figure 11.




Table 5: Safe practices and management of Diabetes during Ramadan among primary healthcare physicians,

Ministry of Health, Makkah Safe practices and Management

of Diabetes During Ramadan

Strongly

agree

N(%)

Agree

N(%)

Neither

agree or

disagree N

(%)

Disagree

N (%)

Strongly

disagree

N (%)

Detailed history 73

(91.2)

6

(7.5)

0

(0.0)

1

(1.3)

0

(0.0)

Patient's experience during

previous Ramadan

52

(65.0)

26

(32.5)

0

(0.0)

2

(2.5)

0

(0.0)

Patient's ability to self-

manage diabetes

44

(54.9)

32

(40.0)

0

(0.0)

1

(1.3)

3

(3.8)

Educate the patients the risk

quantification

52

(65.0)

21

(26.1)

1

(1.3)

3

(3.8)

3

(3.8)

Educate the patients the role of

SMBG

52

(65.0)

23

(28.7)

1

(1.3)

1

(1.3)

3

(3.8)

Educate the patients when to break

the fast

65

(81.2)

10

(12.5)

0

(0.0)

2

(2.5)

3

(3.8)

Educate the patients when

to exercise

54

(67.5)

23

(28.7)

0

(0.0)

1

(1.3)

2

(2.5)

Educate the patients the fluid

and meal planning

57

(71.2)

22

(27.5)

0

(0.0)

0

(0.0)

1

(1.3)

Educate the patients the

medication adjustments during

fasting

72

(89.9)

7

(8.8)

0

(0.0)

0

(0.0)

1

(1.3)

Figure 11: Percentage of the total safe practice in management of diabetes score during Ramadan among the participants.




Factors associated with safe practice -Socio-demographic factors Table 6 shows that none of the studied factors (age, gender, nationality, marital status, current professional grade, training in Family Medicine program, duration spent in reading about diabetes and experience in the current place) was significantly associated with safe practice regarding management of type 2 diabetes in Ramadan. Table 6: Socio-demographic factors associated with safe practice of management of Type2 Diabetes Mellitus during

Ramadan among family physicians, primary health care centers, Ministry of the Health, Makkah- Al Mukarramah city.

Percentage of practice score p-value

Median IQR Mean

rank

Gender

Male (n=37) Female

(n=43)

95.6

97.8

91.1-98.9

88.9-100

38.86

41.91

0.551**

Age (years)

r*

-0.12

0.288

Nationality Saudi

(n=77) Non-Saudi (n=3)

95.6

100

91.1-100

97.8-100

39.69

61.33

0.122**

Marital status Single (n=15)

Ever married (n=65)

95.6

95.6

91.1-100

90-100

40.70

40.45

0.970**

Current professional grade

Specialist (n=41)

Consultant (n=39)

97.8

93.3

91.1-100

91.1-97.8

44.12

36.69

0.114**

Trainer in Family Medicine program No (n=26)

Yes (n=54)

95.6

95.6

91.1-100

90.6-100

39.31

41.07

0.745**

Duration (hours per week) spent by physicians in reading about diabetes

r*

0.003

0.981

Experience in the current practice

(years) ≤5 (n=40) 6-10 (n=30)

>10 (n=10)

97.8 95.6

93.3

91.1-100 83.9-100

90.6-98.3

42.81 38.88

36.10

0.626‡

* Spearman`s coefficient of correlation ** Mann-Whitney test ‡ Kruskal-Wallis test

Professional and work-related factors Physicians who have managed <10 diabetic patients/clinic and those who managed 15 or more patients were

more likely to express safe practice in management of diabetes in Ramadan compared to those who managed between 10 and 14 patients/clinic Mean ranks were 45.32 and 44.75 versus 32, respectively), p=0.049. Other studied factors (history of having access to the online medical library, history of attending conferences, workshop, seminars, courses about diabetes management during Ramadan during the past year academic, guideline mostly followed for management of diabetes during Ramadan, history of diabetes among the participants, and history of working in a CBAHI accredited primary healthcare center) were not significantly associated with safe practice regarding management of type 2 diabetes in Ramadan. Table 7




Table 7: Professional and work-related factors associated with safe practice of management of Type2 Diabetes Mellitus during Ramadan among family physicians, primary health care centers, Ministry of the Health, Makkah- Al

Mukarramah city Percentage of practice score p-value

Median IQR Mean

rank

History of having access to

the online medical library

among the participants

No (n=33) 95.6 90-98.9 38.36

Yes (n=47) 95.6 91.1-100 42.0 0.482*

History of attending

conferences, workshop,

seminars, courses about

diabetes management

during Ramadan during the

past year academic among

the participants

No (n=35) 95.6 91.1-100 39.43

Yes (n=45) 95.6 91.1-100 41.33 0.710*

Guideline mostly followed

for management of diabetes

during Ramadan among the

participants

ADA (n=51) 95.6 88.9-100 39.46

AACE/ACE (n=3) 100 93.3-100 55.17

IDF (n=23) 93.3 91.1-100 38.98

Others (n=3) 100 93.3-100 55.17 0.440**

Average number of diabetic

patients managed per clinic

<10 (n=30) 97.8 97.8-100 45.32

10-14 (n=28) 93.3 88.9-97.2 32.0

≥15 (n=22) 97.8 92.8-100 44.75 0.049**

History of diabetes among

the participants

No (n=76) 95.6 91.1-100 40.53

Yes (n=4) 96.7 72.2-99.4 39.88 0.958*

History of working in a

CBAHI accredited primary

healthcare center

No (n=30) 95.6 88.9-100 39.52

Yes (n=50) 95.657 91.1-100 41.09 0.765*

*Mann-Whitneytest ** Kruskal-Wallistest

4. DISCUSSION: Fasting of diabetic patients during Ramadan in Islamic countries, including KSA is a major challenge for

healthcare professionals, particularly primary healthcare physicians as regards the risk stratification of these patients

according to hypoglycemia, hyperglycemia, co-morbidities, and type of diabetes (11, 14, 15)

. Management of diabetes

during Ramadan should aim at decreasing these risks through the implementation of an effective educational program

before, during and after Ramadan (16). Knowledge of DM among both physicians and patients is mandatory for

appropriate self-management during Ramadan. Therefore, the present study was carried out to evaluate knowledge

and practice of management of type 2 Diabetes Mellitus during Ramadan and identify its associated factors among




family physicians in the primary health care centers in Makkah.

The guideline mostly followed for management of diabetes during Ramadan among the participants in the

present study was ADA. The same has been reported in a similar study carried out in United Arab of Emirates (UAE)(7).

First of all, we have to say that this study is one of the very few studies carried out worldwide and in our region

investigating the knowledge and practice of primary healthcare physicians regarding fasting of diabetic patients during

Ramadan. It revealed that the majority of family physicians (specialists and consultants) knew that diabetic patients

whose blood glucose level was <70 mg/dl should break their fast while half of them knew that those whose blood

glucose level was >300 mg/dl should break their fast. However, only a quarter of them could recognize the frequency

of advised self-monitoring of blood glucose (SMBG) in high risk patient according to IDF. Conclusively, the adequate

knowledge of basic concepts and management skills regarding type 2 diabetes management during Ramadan was

observed among 46.2% of the physicians. In UAE (7)

, two-thirds of physicians were knowledgeable of the risks of

hyperglycemia and diabetic ketoacidosis.

Regarding knowledge of non-insulin dose modification during Ramadan among type 2 diabetics, majority of the

participants knew that daily dose of metformin remains unchanged during Ramadan. However, only 46.3% and

31.3% knew that the dosageofThiazolidinedioneandAcarboseshouldremainun-changedduringRamadan. Also,

majority of physicians knew that Iftar dose of sulphonylurea remains un-changed and Suhoor dose should be reduced

in patient with good glycemic control. Conclusively, adequate knowledge regarding non-insulin dose modification

during Ramadan was observed among 81.2% of the physicians. In UAE (7)

, there was a good awareness level of the

fact that sulphonylurea carries a hypoglycemic risk potential, which was not consistent with the perception of

physicians in another relatively recent study (17). Many physicians would maintain metformin in the same and daily

doses reflecting the widely recognized low hypoglycemic risk of these classes (18, 19). Nearly two-thirds of

respondents in the present study were aware that sulphonylureas doses are traditionally reduced and given before

Suhoor.

Concerning nutritional plan knowledge, 48.8% of the physicians in this study knew that plenty of water

should be of start atIftar in Ramadan while only 15% knew that protein and fat should be consumed in adequate

amount at Suhoor. Conclusively, adequate knowledge regarding nutrition plan during Ramadan was observed among

23.7% of the physicians. Almalki reported that diabetic patients should be advised in order to avoid post-

mealhyperglycemia to eat two or small three meals healthy balanced diet between after and suhoor, rather than

one large meal (18).

Regarding insulin management, almost two-thirds of the physicians knew the frequency of performing the

blood glucose self-measuring (BSM) by patients and make the titration and adjustments of the dose accordingly.

Regarding insulin dose modifications for patients with T2DM during Ramadan, 60% knew that Premixed insulin BID

should be taken as usual morning dose at iftar and reduce evening dose by 25–50% and take at suhoor while only 30%

knew that for Premixed insulin OD, they should take normal dose at iftar. Conclusively, the adequate knowledge

regarding insulin management during Ramadan was observed among 21.2% of the physicians. In a similar UAE study

(7), most physicians recognized the need to monitor blood glucose during the day

(20) and the usual practice of

reversing the premixed insulin doses between day and night but only one third agreed with the possible need to

reduce basal insulin to avoid hypoglycemia (21)

. Overall, 41.2% of the participated physicians in the current study had

adequate knowledge (>60%) regarding management type2 Diabetes Mellitus during Ramadan. This relatively

inadequate knowledge of primary care physicians was supported by findings from other studies (22,23).

As quite expected, older physicians, consultants, physicians who reported having access to the online medical

library and those who have attended conferences, workshop, seminars, and courses about diabetes management

during Ramadan during the past academic year were more knowledgeable about management of type 2 diabetes

during Ramadan than their counterparts. Because of all participants were either specialists or consultants from

primary care settings, there was no remarkable difference regarding most of variables investigate for the association

with knowledge level.

Despite the importance of Ramadan-focused educational programs for physicians, less than half of the

physicians in this study (43.7%) had attended conferences, workshop, seminars, and courses about diabetes

management during Ramadan during the past academic year. Also, in this study, finding that attendance of such




activities improved the physicians` knowledge, necessitates paying more attention to physicians` education in this

regards.

In the current study, majority of the physicians agreed that education of the patients regarding the fluid and

meal planning, the medication adjustments during fasting, when to exercise, when to break the fast and the risk

quantification are safe practices in management of diabetes during Ramadan. In UAE (7)

, majority of physicians

acknowledged the importance of Ramadan-focused education. Results of The Epidemiology of Diabetes and Ramadan

(EPIDIAR) study (24), and those of CREED study (23) have indicated that effective diabetes educational programs

before Ramadan are available in a large number of healthcare centers in different countries. Additionally, the majority

of physicians in both surveys agreed on several key criteria to identify risk stratification of fasting, including the type of

diabetes and type of treatment. Hassanein et al (11)

. reported that 96.4% of the physicians in their study agreed with

the American Diabetic Association (ADA) guidelines regarding the importance of Ramadan-focused educational

programs. Also in the present study, majority of the physicians recognized that patient's experience during previous

Ramadan, the role of SMBG, patient's ability to self-manage diabetes and detailed history are essential practices in

management of diabetes during Ramadan. In a study carried out in UAE (7) most of the physicians were aware of the

importance of glycemic control at night time and were familiar with the time of highest risk of hypoglycemia. In

another UAE study (11)

, only 53.7% of physicians believed that frequent SMBG is necessary in insulin-treated fasting

diabetic patients whereas only 8.1% of them considered SMBG important only in case of suspected hypoglycemia or

hyperglycemia and 38.2% believed that performing SMBG once or twice per day would be sufficient.

Overall, the practice of the physicians in the present study and also in that carried out in UAE is satisfactory in many

aspects. Mostly because of the high prevalence of diabetes in these countries and familiarity of the physicians with

the patient`s behavior during Ramadan fasting.

In the present survey, physicians who managed less number of patients expressed better practice than those

who managed moderate number of patients mostly they are consultants and also those managed more number of

patients also had better practice due to their higher experience with patients.

Some few limitations of the present study have to be mentioned. First of all, conduction of the study among only

specialists and consultants could impact the generalizability of results over the entire population of primary

healthcare physicians in Makkah. The relative small sample size of the subgroups made statistical comparison very

difficult to be significant. Finally, the questionnaire was self-administered; therefore accurate responses may have

been impaired by the inability to clarify questions and also subjected to information bias. Despite those limitations,

the study is unique in our area and could help in improving knowledge and practice of primary health care physicians

in achieving better management of diabetes during Ramadan fasting.

5. CONCLUSION The present study`s results offer an insight into the knowledge and approaches adopted by family physicians

in Makkah regarding management of type 2 diabetes among fasting patients during Ramadan. The guideline mostly followed for management of diabetes during Ramadan among them was ADA, followed by IDF. Adequate knowledge of basic concepts/management skills, nutrition plan and insulin management of type 2 diabetes during Ramadan were not satisfied. However, their knowledge regarding non-insulin dose modification was satisfactory. Overall, inadequate knowledge was observed among more than half of them. Older physicians, consultants, physicians who reported having access to the online medical library and those who had a history of attending conferences, workshop, seminars, and courses about diabetes management during Ramadan were more knowledgeable regarding management of type 2 diabetes in Ramadan than others. The safe practice of management of diabetes during Ramadan was adequate. Physician`s number of managed patients was associated with more safe practice.

6. RECOMMENDATIONS 1. Planning and implementing educational programs regarding management of type 2 diabetes during Ramadan

such as attending conferences, workshop, seminars, and courses about diabetes management during

Ramadan. These programs should target both treating physicians and patients separately.

2. Specific attention should be given to younger and less ranked physicians regarding training in management of

diabetes during Ramadan

3. Encourage physicians to have an access to the online medical library and providing this service at workplace

whenever possible.




4. Development of simple guidelines and educational materials that could be easily accessed by physicians as

well as patients is needed

5. Further study is warranted including all primary healthcare physicians in Makkah from different disciplines.

6. Another study is recommended to be conducted among patients to assess their knowledge, beliefs and

practices regarding management of diabetes during Ramadan.

7. REFERENCES 1. 1. Stonawski M, Skirbekk V, Potančoková M. The future of world religions: population growth projections, 2010-2015.2015. 2. 2. Mnif F, Slama CB, Chaieb L, Blouza S, Hsairi M. Observational Study of the Tunisian Diabetic Patients' Profile during the

Fasting of the Holy Month of Ramadan. Journal of Endocrinology and Diabetes2016;3(4):1-8. 3. 3. Al Sifri S, Rizvi K. Filling the knowledge gap in diabetes management during Ramadan: the evolving role of trial evidence.

Diabetes Therapy.2016;7(2):221-40. 4. 4. Karamat MA, Syed A, Hanif W. Review of diabetes management and guidelines during Ramadan. Journal of the Royal

Society of Medicine.2010;103(4):139-47. 5. 5. Irshad M, Khan I, Khan FA, Baig A, Gaohar QY. A Survey of awareness regarding diabetes and its management among

patients with diabetes in Peshawar, Pakistan. Journal of Postgraduate Medical Institute (Peshawar-Pakistan).2015;28(4). 6. 6. Zargar A. Diabetes control during Ramadanfasting. Cleveland Clinic journal of medicine. 2017;84(5):352. 7. 7. Beshyah SA, Farooqi MH, Farghaly M, Abusnana S, Al Kaabi JM, Benbarka MM. Management of Diabetesduring Ramadan

Fasting: A Comprehensive Survey of Physicians’ Knowledge, Attitudes and Practices. Ibnosina Journal of Medicine and Biomedical Sciences. 2017;9(2):28-36.

8. 8. Zainudin SB, Ang DY, Soh AWE. Knowledge of diabetes mellitus and safe practices during Ramadan fasting among Muslim patients with diabetes mellitus in Singapore. Singapore medical journal.2017;58(5):246.

9. 9. Lee JY, Wong CP, San San Tan C, Nasir NH, Lee SWH. Type 2 diabetes patient’s perspective on Ramadan fasting: a qualitative study. BMJ Open Diabetes Research and Care. 2017;5(1):e000365.

10. Jamoussi H, Ben Othman R, Chaabouni S, Gamoudi A, Berriche O, Mahjoub F, et al. Interest of the therapeutic education in patients with type 2 diabetes observing the fast of Ramadan. Alexandria Journal of Medicine.2017;53(1):71-5.

11. Hassanein M, Bashier A, Abdelgadir E, Al Saeed M, Alawadi F, Khalifa A. Survey of the knowledge and attitude of physicians toward the management of diabetes mellitus during Ramadan. Journal of Fasting and Health. 2016;4(3):117-21.

12. AlSlailFY, RashidHU, FadlSM, KheirOO. Physician Awareness in Diabetes Management During Ramadan 2015—A Focus Group Discussion. US Endocrinology. 2017;13(1):30-4.

13. Wilbur K, Al Tawengi K, Remoden E. Diabetes patient management by pharmacists during Ramadan. BMC health services research.2014;14(1):117.

14. Ali S, Davies MJ, Brady EM, Gray LJ, Khunti K, Beshyah SA et al. Guidelines for managing diabetes in Ramadan. Diabet Med 2016;33(10):1315-29.

15. Beshyah SA, Benbarka MM, Sherif IH. Practical management of diabetes during Ramadan fast. Libyan J Med 2007;2(4):185-9.

16. Al-Arouj M, Assaad-Khalil S, Buse J, Fahdil I, Fahmy M, Hafez S, et al. Recommendations for management of diabetes during Ramadan: update 2010. Diabetes Care 2010;33(8):1895– 902.

17. Mbanya JC, Al-Sifri S, Abdel-Rahim A, Satman I. Incidence of hypoglycemia in patients with type 2 diabetes treated with gliclazide versus DPP-4 inhibitors during Ramadan: a meta- analytical approach. Diabetes Res Clin Pract2015;109:226-32.

18. Almalki MH, Alshahrani F. Options for controlling Type 2 Diabetes during Ramadan. Front Endocrinol (Lausanne) 2016;7:32. 19. Beshyah SA, Farooqi MH, Suliman SGI, Benbarka M. Use of sodium-glucose co-transporter 2 inhibitors during the fasting of

Ramadan: Is there cause for concern? Ibnosina J Med BS 2016; 8(3):81-8. 20. Recommendations of the 9th Fiqh-Medical seminar “An Islamic View of Certain Contemporary Medical issues,” Casablanca,

Morocco, 14–17 June, 1997. Islamic Organization of Medical Sciences. Decree3.

21. Kobeissy A, Zantout MS, Azar ST. Suggested insulin regimens for patients with type 1 diabetes mellitus who wish to fast

during the month of Ramadan. Clin Ther2008;30(8):1408-15.

22. Gaborit B, Dutour O, Ronsin O, Atlan C, Darmon P, Gharsalli R, et al. Ramadan fasting with diabetes: an interview study of

inpatients' and general practitioners' attitudes in the South of France. Diabetes Metab. 2011;37(5):395-402.

23. Babineaux SM, Toaima D, Boye KS, Zagar A, Tahbaz A, Jabbar A, et al. Multi-country retrospective observational study of the

management and outcomes of patients with Type 2 diabetes during Ramadan in 2010 (CREED). Diabet Med. 2015;

32(6):819- 28.

24. Salti I, Bénard E, Detournay B, Bianchi-Biscay M, LeBrigand C, Voinet C, et al. A population-based study of diabetes and its

characteristics during the fasting month of Ramadan in 1376 countries: results of the epidemiology of diabetes and

Ramadan.


Documents

Knowledge and practice of Management Type2 Diabetes ...ijcmsdr.com/Vol-1-Is-4/C-070-2240.pdf · of attending conferences, workshop, seminars, courses about diabetes management during