ZIA ASHRAF

M.Phil
zeezila@yahoo.com
“ O you who believe! Fasting has been
prescribed to you as it was prescribed to
those before you so that you attain Taqwa
(self restraint , God Awareness)”
1. Physically sick ( Quran 2: 184-185)
2. Traveler on a journey ( Quran 2: 184-185)
3. Women during menstruation
4. ? Pregnant and lactating women
5. Pre pubertal children
 Diabetes Mellitus Type 1
 Chronic Renal Failure including Renal
Transplant and Nephrolithiasis
 Severe cardiac and pulmonary conditions
 G.I. Bleed and acute ulcers
 Severe Epilepsy
 Severe Migraine
 Estimated 1.1-1.5 billion Muslims worldwide.
 Fasting during Ramadan is obligatory on
every adult Muslim.
 Muslims fast for 29-30 days of lunar based
month.
 Fasting starts before sunrise and end at
sunset and the duration of the day varies as
the season.
 What are evidences we have to support
today’s talk
 Epidemiology of Diabetes and Ramadan 2001
(EPIDIAR)
 Approximately
▪ 43% patients with type 1 diabetes
▪ 79% of patients with type 2 diabetes fast during
Ramadan
 Insulin secretion in healthy individuals is
stimulated with feeding, which promotes the
storage of glucose in liver and muscle as
glycogen.
 In contrast, during fasting, circulating glucose
levels tend to fall, leading to decreased
secretion of insulin, levels of glucagon and
catecholamines rise, stimulating the
breakdown of glycogen, while
gluconeogenesis is augmented
 As fasting becomes protracted for more than
several hours, glycogen stores become
depleted, and the low levels of circulating
insulin allow increased fatty acid release from
adipocytes.
 Oxidation of fatty acids generates ketones
that can be used as fuel by skeletal and
cardiac muscle, liver, kidney, and adipose
tissue, thus sparing glucose for continued
utilization by brain and erythrocytes.
 Hypoglycemia

Hyperglycemia

Diabetic ketoacidosis

Dehydration and thrombosis

Recommendations for Diabetic Individuals during Ramadan, Diabetes Care , vol 33, num. 8, August2010
 Threefold increase in the risk of severe
hypoglycemia in patients who were in the
intensively treated group and had an average
HbA1c (A1C) value of 7.0%.
 2–4% of mortality in patients with type 1
diabetes.
 Severe hypoglycemia was more frequent in
patients in whom the dosage of oral
hypoglycemic agents or insulin were changed
and in those who reported a significant change
in their lifestyle.
 There is no information linking repeated
yearly episodes of short-term hyperglycemia
(e.g., 4-week duration) and diabetes related
complications.
 Control of glycemia in patients with diabetes
who fasted during Ramadan has been
reported to deteriorate, improve, or show no
change.
 Fivefold increase in the incidence of severe
hyperglycemia (requiring hospitalization)
during Ramadan in patients with type 2
diabetes (from 1 to 5 events 100 people1
month1) and
 An approximate threefold increase in the
incidence of severe hyperglycemia with or
without ketoacidosis in patients with type 1
diabetes
 Patients with diabetes, especially those with
type 1 diabetes, who fast during Ramadan are
at increased risk for development of diabetic
ketoacidosis, particularly if they are grossly
hyperglycemic before Ramadan.
 Limitation of fluid intake during the
fast, especially if prolonged, is a cause of
dehydration.
 Hyperglycemia can result in osmotic diuresis and
contribute to volume and electrolyte depletion.
 Orthostatic hypotension, syncope, falls, injuries
and bone fractures may result.
 Patients with diabetes exhibit a hypercoagulable
state due to an increase in clotting factors, a
decrease in endogenous anticoagulants, and
impaired fibrinolysis.
 Most often recommendation will be not to
undertake fasting.
 However, patients who insist on fasting need
to be aware of the associated risks and be
ready to adhere to the recommendations of
their doctors for safe Ramadan.
 Risk stratification
 1. Very high risk
 Severe hypoglycaemia within the last 3 months prior to
Ramadan.
 A history of recurrent hypoglycaemia.
 Hypoglycaemia unawareness.
 Sustained poor glycemic control.
 Ketoacidosis within the last 3 months prior to Ramadan.
 Type 1 Diabetes
 Acute illness
 Pregnancy
 Patients on chronic dialysis
 Patients who perform intense labour

Recommendations for Diabetic Individuals during Ramadan, Diabetes Care , vol 33, num. 8, August2010
2. High risk
 Patients 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 living alone
 Patients with comorbid conditions that present
additional risk factors
 Old age with ill health
 Drugs that may affect mentation
3. Moderate risk
 Well-controlled patients treated with short-
acting insulin secretagogues such as
repaglinide or nateglinide
4. Low risk
 Well-controlled patients treated with diet
alone, metformin, or a thiazolidinedione who
are otherwise healthy
Diabetes Care Volume 33, Number 8, August 2010
 Individualization
 Frequent monitoring of glycemia
 Nutrition
 The diet during Ramadan should not differ
significantly from a healthy and balanced diet.
 The common practice of ingesting large amounts
of foods rich in carbohydrate and fat, especially at
the sunset meal, should be avoided.
 Because of the delay in digestion and
absorption, ingestion of foods containing
“complex” carbohydrates may be advisable at
the predawn meal.
 While foods with more simple carbohydrates
may be more appropriate at the sunset meal.
 It is also recommended that fluid intake be
increased during nonfasting hours and that the
predawn meal be taken as late as possible
before the start of the daily fast.
 Slow energy release foods (such as
wheat, semolina, beans, rice) should be taken
before and after fasting, whereas foods high in
saturated fat (such as ghee, samosas, and
pakoras) should be minimised.
 Advise patients to use only a small amount of
monounsaturated oils (such as rapeseed or olive
oil) in cooking
 Before and after fasting include high fibre foods
such as wholegrain cereals, granary
bread, brown rice; beans and pulses;
fruit, vegetables, and salads
 Individualization
 Frequent monitoring of glycemia
 Nutrition
 Exercise
 Normal levels of physical activity may be maintained.
 Breaking the fast
 All patients should understand that they must always
and immediately end their fast if hypoglycemia (blood
glucose of 60 mg/dl [3.3 mmol/l])
 Fast should be broken if blood glucose exceeds 300
mg/dl (16.7 mmol/l).
 Patients should avoid fasting on “sick days.”
 Medical assessment
 This assessment should take place within 1–2
months before (Rajab, Shaban)Ramadan.
 Overall well-being of the patient and to the
control of their glycemia, blood pressure, and
lipids.
 During this assessment, necessary changes in
their diet or medication regimen should be made
 Educational Counselling
 It is essential that the patients and family receive
the necessary education concerning self-
care, including signs and symptoms of hyper and
hypoglycemia, blood glucose monitoring, meal
planning, physical activity, medication
administration, and management of acute
complications.
 An approach to oral treatment of type 2 diabetes during Ramadan for patients planning to
fast.

Hui E et al. BMJ 2010;340:bmj.c3053

©2010 by British Medical Journal Publishing Group
 In general, patients with type 1
diabetes, especially if “brittle” or poorly
controlled, are at very high risk of developing
severe complications and should be strongly
advised to not fast during Ramadan.
 Glycemic control at near-normal levels
requires use of multiple daily insulin
injections (three or more)
 Diet-Controlled patients
 Potential risk for occurrence of postprandial
hyperglycemia after the predawn and sunset
meals if patients overindulge in eating.
 Distributing calories over two to three smaller
meals during the nonfasting interval may help
prevent excessive postprandial hyperglycemia.
 The exercise program should be modified in its
intensity and timing to avoid hypoglycemic
episodes
 In general, agents that act by increasing
insulin sensitivity are associated with a
significantly lower risk of hypoglycemia than
compounds that act by increasing insulin
secretion.
 Metformin.
 Patients treated with metformin alone may safely
fast because the possibility of hypoglycemia is
minimal.
 However, it is suggested that the timing of the
doses be modified.
 Recommendation is that two thirds of the total
daily dose be administered immediately before
the sunset meal, while the other third be given
before the predawn meal.
 Glitazones.
 Patients on insulin sensitizers (rosiglitazone and
pioglitazone) have a low risk of hypoglycemia.
Usually no change in dose is required.
 Sulfonylureas. T
 his group of drugs was believed to be unsuitable for
use during fasting because of the inherent risk of
hypoglycemia. Hence, their use should be
individualized and they should be utilized with
caution.
 Use of chlorpropamide is absolutely contraindicated
during Ramadan because of the high possibility of
prolonged and unpredictable hypoglycemia.
 Newer members of the sulfonylurea family (gliclazide
MR or glimepiride) have been shown to be
effective, resulting in a lower risk of hypoglycemia
 Short-acting insulin secretagogues.
 Members of this group (repaglinide and
nateglinide) are useful because of their short
duration of action.
 They could be taken twice daily before the sunset
and predawn meals.
 Patients treated with insulin
 A major objective is to suppress hepatic glucose
output to near-physiologic levels during the fasting
period.
 Judicious use of intermediateor long-acting insulin
preparations plus a short-acting insulin administered
before meals would be an effective strategy.
 Using one injection of a long-acting insulin
analog, such as insulin glargine, or two injections of
NPH, lente, or detemir insulin before the sunset and
predawn meals may provide adequate coverage.
 Patients treated with insulin
 However, most patients will still require short-
acting insulin administered in combination with
the intermediate- or long- acting insulin at the
sunset meal to cover the large caloric load of Iftar.
 Moreover, many will need an additional dose of
short-acting insulin at predawn.
 Dehydration, volume depletion, and a tendency
toward hypotension may occur with fasting
during Ramadan.
 Hence, the dosage of antihypertensive
medications may need to be adjusted to
prevent hypotension.
 It is common practice that the intake of foods
rich in carbohydrates and saturated fats is
increased during Ramadan. Appropriate
counselling should be given to avoid this
practice.
 Fasting during Ramadan for patients with
diabetes carries a risk of an assortment of
complications.
 Patients with type 1 diabetes should be
strongly advised to not fast.
 Hypo- and hyperglycemia may also occur in
patients with type 2 diabetes but generally
less frequently and with less severe
consequences compared with patients with
type 1 diabetes.
 Patients who insist on fasting should undergo
pre-Ramadan assessment and receive
appropriate education and instructions related
to physical activity, meal planning, glucose
monitoring, and dosage and timing of
medications.
 The management plan must be highly
individualized.
 Close follow-up is essential to reduce the risk for
development of complications.