This presentation is a part of More on Islam presentation series. For other titles please contact [email protected]

This presentation is a part of More on Islam presentation series. For other titles please contact [email protected]


Management of Diabetes Management of Diabetes

During RamadanDuring Ramadan

Amir Ziaee, M.D.

Professor of Internal Medicine & Endocrinology


�ِذ�يَن� اَّل َع�َل�ى �َب� �ِت ُك �َم�ا ُك �اُم� اَّلِّص�َي �ُم� �ُك �َي َع�َل �َب� �ِت ُك � �وا آَم�ُن �ِذ�يَن� اَّل �َه�ا ي� َأ �ا ي

�ُق�وَن� �ِت َت �ُم� �ُك �َع�َل َّل �ُم� �ُك �َل َق�ْب َم�َن

The goal of fasting is to develop self-restraint.

Holy Quran states: “O you who believe! Fasting is prescribed to you as it was prescribed to those before you, so that you may develop Taqwa (self-restraint) ” [2:183]

Fear of GodLove of God +

What is Taqwa? Taqwa is an Arabic word. It is the state of heart that motivates virtuous conduct and prevents evil action.

leads to Taqwa (Self-restraint)

Example: God says about Mary in the Qur’an that she said: “Verily!, I have vowed a fast to the Most

Beneficent…[Maryam 19:26].

Example: God says about Mary in the Qur’an that she said: “Verily!, I have vowed a fast to the Most

Beneficent…[Maryam 19:26].

Taqwa is the ability to safe-guard.


Benefits of Fasting in Islam : How character-building is

achieved…

Taqwa (Self-restraint)FastingFasting

Patience

Self-control

Self-discipline

Responsibility

Obedience

Purification of soul

God-fearing nature

Afterlife Accountability


Changes in Carbohydrates Changes in Carbohydrates

Metabolism During Fasting Metabolism During Fasting

of Ramadanof Ramadan


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Free Tatty Acids

Ketone Bodies

Glucose

7


The effect of Ramadan fasting on metabolism and different organs in healthy individuals

Metabolism/organ Effect

Carbohydrate Glycogenolysis of the liver, some degree of gluconeogenesis in longer fasting days

Lipids Variable, depending on the quality and quantity of diet and weight change

Body weight Variable, mostly decreased or unchanged

Liver Slight increase in indirect bilirubin in the first half of Ramadan fasting

Kidney Small, insignificant changes in serum urea, creatinine and uric acid

Hematological Profile Small decrease in both iron and total iron binding capacity

Neuropsychiatric Change in chronotype and sleep patterns; increase in the prevalence of headaches;

Endocrine Glands Slight changes in protein binding of T4 and T3 and in serum calcium concentrationSmall reversible shifts in cortisol, testosterone and prolactin secretions

Gastrointestinal tract, heart, lungs and eyes

None


How many people with diabetes fast during Ramadan?

Type of diabetes1 2

Fast

During

Ramadan

43% 79%

50 million Muslims with diabetes fast each year

Salti et al. Diabetes Care 2004; 27: 2306


Major risks associated with fasting in patients with diabetes

Hypoglycemia

Hyperglycemia

Diabetic ketoacidosis

Dehydration and thrombosisDiabetes Care 2004; 28: 2305Al-Arouj et al. Diabetes Care 2010; 33: 1895


Categories of risks in patients with type 1 or type 2

diabetes who fast during Ramadan

Very high riskSevere hypoglycemia within the last 3 months prior to Ramadan Patient with a history of recurrent hypoglycemia

Patients with hypoglycemia unawareness Patients with sustained poor glycemic control Ketoacidosis within the last 3 months prior to Ramadan Type 1 diabetes Acute illness

Hyperosmolar hyperglycemic coma within the previous 3 months Patients who perform intense physical labor

Pregnancy Patients on chronic dialysis

Al-Arouj et al. Diabetes Care 2010; 33: 1895


Categories of risks in patients with type 1 or type 2 diabetes who fast during Ramadan

High riskPatients with moderate hyperglycemia (average blood glucose between 150 and 300 mg/dl,

A1C 7.5–9.0%)

Patients with renal insufficiency

Patients with advanced macrovascular complications

People living alone that are treated with insulin or sulfonylureas

Patients with comorbid conditions that present additional risk factors

Old age with ill health

Drugs that may affect mentation

Moderate riskWell-controlled patients treated with short-acting insulin secretagogues such as repaglinide

or nateglinide

Low riskWell-controlled patients treated with diet alone, metformin, acarbose, thiazolidinedione or incretion drugs who are otherwise healthy

Al-Arouj et al. Diabetes Care 2010; 33: 1895



Management of Patients with Type 2 Diabetes on Insulin

Use of a rapid acting insulin analog instead of regular

human insulin before meals in patients with type 2

diabetes who fast during Ramadan is associated with less

hypoglycemia and smaller postprandial glucose

excursions.


Recommended changes to insulin

regimen in patients with type 2

diabetes who fast during Ramadan


If patient is on premix insulin therapy

Use the usual morning dose at the sunset meal (Iftar)

and half the usual evening dose at predawn (sahur),

e.g., 70/30 premixed insulin 30 units in the morning and 20

units in the evening before Ramadan (BHI 30 or BIAsp 30),

during Ramadan recommended dose will be 30 units in

evening and 10 units at sahur; also consider changing to

basal plus bolus.


If on Basal Bolus insulin therapy

■Bolus portion

Morning dose: Transfer full dose at iftaar.Evening dose: Transfer ½ dose at sahur.Lunch dose: If patient takes dinner, transfer the full dose at dinner.


If on Basal Bolus insulin therapy

Basal portion

If patient is on NPH: 50% dose at sahur.

If patient is on basal analog: Same dose at bed time.


Blood Glucose Monitoring During Ramadan

Adjust insulin dose at 3 days' interval

- Pre-iftaar: adjust basal insulin dose

- 2 hours post-iftaar: adjust iftaar bolus insulin dose

- 2 hours postdinner: adjust dinner bolus insulindose

- 2 hours post-sahur: adjust sahur bolus insulin dose.


Blood Glucose Monitoring During Ramadan

If blood glucose is noted to be low, fasting

must be broken.

If blood glucose > 300 mg/dl or 16.66

mmol/L, ketones in urine should be

checked.


Conclusion

It is possible for people with diabetes to fast safely during Ramadan, but requires careful planning in order to avoid problems that could be serious and have long-term effects.

The choice of insulin therapy is decided by the previous therapy that the patient is taking and also the blood glucose profiles.


Conclusion

The major objective of insulin therapy during Ramadan

is to provide adequate insulin to prevent the post meal

hyperglycemia and also prevent hypoglycemia during

the period of fast.

With the use of analogues these objectives may be met

more easily.


Thanks for your attention

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This presentation is a part of More on Islam presentation series. For other titles please contact [email protected]