This presentation is a part of More on

This presentation is a part of More on Islam presentation series. For other titles please contact moreonislam@hotmail. com

DIABETES and RAMADAN Fereidoun Azizi, M. D. Research institute for Endocrine Sciences Shahid Beheshti University of Medical Sciences Tehran, I. R. Iran This presentation is a part of More on Islam presentation series. For other titles please contact moreonislam@hotmail. com

OBJECTIVE Ø To review changes in metabolism of carbohydrates during fasting of Ramadan Ø To present the evidence-based management of diabetic patients during Ramadan Ø To discuss practical management of diabetic cases during Ramadan This presentation is a part of More on Islam presentation series. For other titles please contact moreonislam@hotmail. com

ﺍ ﺍﻟ ﺍ ﺍﻳ ﻯ ﻥ The goal of fasting ﻭ 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 (selfrestraint) ” [2: 183] 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]. What is Taqwa? Love of God + Taqwa is an Arabic word. It is the state of heart that motivates virtuous conduct and prevents evil action. Fear of God leads to Taqwa (Self-restraint) Taqwa is the ability to safe-guard. This presentation is a part of More on Islam presentation series. For other titles please contact moreonislam@hotmail. com

Changes in Carbohydrates Metabolism During Fasting of Ramadan This presentation is a part of More on Islam presentation series. For other titles please contact moreonislam@hotmail. com

This presentation is a part of More on Islam presentation series. For other titles please contact moreonislam@hotmail. com

Glucose Turnover 1. Absorptive: 8 -12 hr 2. Post absorptive: 5 -6 hr 3. Gluconeogenesis This presentation is a part of More on Islam presentation series. For other titles please contact moreonislam@hotmail. com

This presentation is a part of More on Islam presentation series. For other titles please contact moreonislam@hotmail. com

This presentation is a part of More on Islam presentation series. For other titles please contact moreonislam@hotmail. com

This presentation is a part of More on Islam presentation series. For other titles please contact moreonislam@hotmail. com

Serum glucose during Ramadan Serum glucose may decrease slightly in the first few days of Ramadan fasting, normalizing by the 20 th day and showing a slight rise by the 29 th day. The lowest serum glucose level in this study was 63 mg/dl. Other studies have shown a mild increase or variation in serum glucose concentration This presentation is a part of More on Islam presentation series. For other titles please contact moreonislam@hotmail. com

Change in serum glucose concentration This presentation is a part of More on Islam presentation series. For other titles please contact moreonislam@hotmail. com

Mean continuous glucose monitoring (CGM) profiles from patients with diabetes before and during Ramadanme A rapid rise in blood glucose is seen at iftar time* Lessan N, Hannoun Z, Hasan H, et al. Glucose excursions and glycaemic control during Ramadan fasting in diabetic patients: Insights from continuous glucose monitoring (CGM). Diabetes Metab 2015; 41: 28 -36. This presentation is a part of More on Islam presentation series. For other titles please contact moreonislam@hotmail. com

Longer fasting During longer fasting days of >16 h, which follow a rather heavy meal taken before dawn (Sahur), the stores of glycogen, along with some degree of gluconeogenesis, maintain serum glucose levels within normal limits. Since gluconeogenesis becomes the only source of glucose after 16 – 24 h of fasting, it is recommended that observers of fasts do not skip Sahur, their predawn meal, because of the possibility of extended gluconeogenesis. This presentation is a part of More on Islam presentation series. For other titles please contact moreonislam@hotmail. com

Evidence- Based Management of Diabetes During Ramadan This presentation is a part of More on Islam presentation series. For other titles please contact moreonislam@hotmail. com

The growing problem of diabetes in Muslimmajority countries International Diabetes Federation. IDF Diabetes Atlas (Seventh Edition). 2015; Available at: http: //www. diabetesatlas. org/resources/2015 -atlas. html. Accessed 17 February 2016. This presentation is a part of More on Islam presentation series. For other titles please contact moreonislam@hotmail. com

Fasting in type 1 diabetics • Glucagon secretion fails to increase • Epinephrine secretion is defective • Prolonged fast: Excessive glycogen breakdown Increased gluconeogenesis Ketoacidosis 18 This presentation is a part of More on Islam presentation series. For other titles please contact moreonislam@hotmail. com

Changing in lifestyle during Ramadan Dietary Habits Glycemic Control 1. Introduction Daily Physical Activity Lipid Profile 2. Risk of fasting for diabetes Sleeping Pattern Weight & Dietary Intakes 3. Nutritional considerations This presentation is a part of More on Islam presentation series. For other titles please contact moreonislam@hotmail. com

Care of Diabetics in Ramadan q Many Muslims, even those who could seek exemption, have an intense desire to participate in fasting during Ramadan. q Most of the guidance available for the management of diabetes during Ramadan represents expert opinion rather than medical evidence. q Generating optimised Ramadan-specific treatment regimens for each patient is essential if a physician is to offer the best possible care. IDF, Diabetes and Ramadan: Practical Guidelines, April 2016 This presentation is a part of More on Islam presentation series. For other titles please contact moreonislam@hotmail. com

Up to 79% of Muslims with diabetes fast for at least 15 days during Ramadan Salti I, Benard E, Detournay B, et al. A population-based study of diabetes and its characteristics during the fasting month of Ramadan in 13 countries: results of the epidemiology of diabetes and Ramadan 1422/2001 (EPIDIAR) study. Diabetes Care 2004; 27: 2306 -11. This presentation is a part of More on Islam presentation series. For other titles please contact moreonislam@hotmail. com

A Population-Based Study of Diabetes and Its Characteristics During the Fasting Month of Ramadan in 13 Countries Results of the Epidemiology of Diabetes and Ramadan 1422/2001 (EPIDIAR) study Ibrahim Salti, MD, PHh. D, Eric Benard, MD, Bruno Detournay, MD, MBA, Monique Biscay, MD, Corinne Le Brigand, Celine Voinet, Abdul Jabbar, MD, on behalf of the EPIDIAR Study Group* Diabetes Care 2004; 27: 2306 This presentation is a part of More on Islam presentation series. For other titles please contact moreonislam@hotmail. com

EPIDIAR study: mean numbers of severe glycaemic events/month during Ramadan compared with before Ramadan Salti I, Benard E, Detournay B, et al. A population-based study of diabetes and its characteristics during the fasting month of Ramadan in 13 countries: results of the epidemiology of diabetes and Ramadan 1422/2001 (EPIDIAR) study. Diabetes Care 2004; 27: 2306 -11. This presentation is a part of More on Islam presentation series. For other titles please contact moreonislam@hotmail. com

Recommenations and education, including counseling for blood glucose control and self-management of diabetes, were dispensed by physicians to 89% of patients with type 1 diabetes and to 80% of patients with type 2 diabetes. However, only 67% of patients with type 1 diabetes and 37% of patients with type 2 diabetes were monitoring blood glucose levels themselves. Salti, et al. Diabetes Care 2004; 27: 2306 This presentation is a part of More on Islam presentation series. For other titles please contact moreonislam@hotmail. com

Change in physical activity and food intake during Ramadan in patients with diabetes Variable Type 1 Type 2 n=1070 N=11, 173 Physical activity More Less Same 11 35 54 9 37 54 Food intake More Less Same 20 23 57 19 30 51 Weight change More Less Same 18 20 62 19 27 54 Salti, et al. Diabetes Care 2004; 27: 2306 This presentation is a part of More on Islam presentation series. For other titles please contact moreonislam@hotmail. com

Change in dosage of insulin and oral hypoglycemic drugs during Ramadan Variable Type 1 Type 2 n=1070 n=11, 173 Insulin dose Increased Decreased Maintained Stopped 11 24 64 1 8 25 64 3 OAD dose Increased Decreased Maintained Stopped 5 15 79 1 4 19 75 2 Salti, et al. Diabetes Care 2004; 27: 2306 This presentation is a part of More on Islam presentation series. For other titles please contact moreonislam@hotmail. com

Management of diabetes during Ramadan (continued) Pre –Ramadan Medical Assessments Ramadan Focused Structured Education • Assess the clinical profile • Evaluation the risk of fasting • Nutrition education • Timing and dosing of medications • Physical activity • Recognizing and managing complications Hui E et al. BMJ 2010; 340: 1407 -1411. Al. Maatouq M. Diabetes, Metabolic syndrome and Obesity: Targets and Therapy 2012; 5: 109 -11. This presentation is a part of More on Islam presentation series. For other titles please contact moreonislam@hotmail. com

Key components of a Ramadan-focused educational programme a. Assessment of physical well being; b. c. Assessment of metabolic control; Adjustment of the diet protocol for Ramadan fasting; d. e. Adjustment of drug regimen; Encouragement of continued proper physical activity; f. Recognition of warning symptoms dehydration, hypoglycemia. IDF, Diabetes and Ramadan: Practical Guidelines, April 2016 This presentation is a part of More on Islam presentation series. For other titles please contact moreonislam@hotmail. com

Factors for risk quantification IDF, Diabetes and Ramadan: Practical Guidelines, April 2016 This presentation is a part of More on Islam presentation series. For other titles please contact moreonislam@hotmail. com

Recommendations for Management of Diabetes During Ramadan Monira Al-Arouj, MD, Radhia Bouguerra, MD, John Buse, MD, Ph. D, Sherif Hafez, MD, FACP, Mohamed Hassanein, FRCP, Mahmoud Ashraf Ibrahim, MD, Faramarz Ismail-Beigi, MD, Ph. D, Imad El-Kebbi, MD, Oussama Khatib, MD, Phd, Suhail Kishawi, MD, Abdulrazzag Al-Madani, MD, Aly A. Mishal, MD, FACP, Masoud Al-Maskari, MD, Phd, Abdalla Ben Nakhi, MD and Khaled Al-Rubean, MD Diabetes Care 2004; 28: 2305 Al-Arouj et al. Diabetes Care 2010; 33: 1895 This presentation is a part of More on Islam presentation series. For other titles please contact moreonislam@hotmail. com

Major risks associated with fasting in patients with diabetes Hypoglycemia Hyperglycemia Diabetic ketoacidosis Dehydration and thrombosis Diabetes Care 2004; 28: 2305 Al-Arouj et al. Diabetes Care 2010; 33: 1895 This presentation is a part of More on Islam presentation series. For other titles please contact moreonislam@hotmail. com

Categories of risks in patients with type 1 or type 2 diabetes who fast during Ramadan Very high risk Severe 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 with 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 This presentation is a part of More on Islam presentation series. For other titles please contact moreonislam@hotmail. com

Categories of risks in patients with type 1 or type 2 diabetes who fast during Ramadan High risk Patients with moderate hyperglycemia (average blood glucose between 150 and 300 mg/dl, A 1 C 7. 5– 9. 0%) Patients with renal insufficiency Patients with advanced macro vascular 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 Al-Arouj et al. Diabetes Care 2010; 33: 1895 This presentation is a part of More on Islam presentation series. For other titles please contact moreonislam@hotmail. com

Categories of risks in patients with type 1 or type 2 diabetes who fast during Ramadan Moderate risk Well-controlled patients treated with short-acting insulin secretagogues such as repaglinide or nateglinide Low risk Well-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 This presentation is a part of More on Islam presentation series. For other titles please contact moreonislam@hotmail. com

RECOMMENDATIONS DURING RAMADAN FASTING I. Nutrition and Ramadan fasting: Dietary indiscretion during the non-fasting period with excessive gorging, or compensatory seating, of carbohydrate and fatty foods contributes to the tendency towards hyperglycemia and weight gain. II. Physical activity and Ramadan fasting: It should be impressed upon diabetic patients that it is necessary to continue their usual physical activity especially during non-fasting periods. This presentation is a part of More on Islam presentation series. For other titles please contact moreonislam@hotmail. com

Site and mode of action of the most commonly used antidiabetic pharmacological agents, classified by their hypoglycemic risk potential and weight gain/loss characteristics. Almaatouq MA. Diabetes Metab Syndr Obes 2012; 5: 109 This presentation is a part of More on Islam presentation series. For other titles please contact moreonislam@hotmail. com

Recommended changes of treatment regimen in patients with type 2 diabetes who fast during Ramadan Before Ramadan During Ramadan Patients on diet and exercise control Patients on oral hypoglycemic agents Biguanide, metformin 500 mg three times a day, or sustained release metformin (glucophage R) No change needed (modify time and intensity of exercise), ensure adequate fluid intake Ensure adequate fluid intake Metformin, 1, 000 mg at the sunset meal (Iftar), 500 mg at the predawn meal (Suhur) TZDs, pioglitazone or rosiglitazone once daily No change needed Incretions (GLP 1 analogies and DPP 4 inhibitors) No change needed This presentation is a part of More on Islam presentation series. For other titles please contact moreonislam@hotmail. com

Recommended changes of treatment regimen in patients with type 2 diabetes who fast during Ramadan Before Ramadan During Ramadan Sulfonylureas once a day, e. g. , Dose should be given before the sunset meal glimepiride 4 mg daily, gliclazide MR (Iftar); adjust the dose based on the glycemic 60 mg daily control and the risk of hypoglycemia Sulfonylureas twice a day, e. g. , glibenclamide 5 mg or gliclazide 80 mg, twice a day (morning and evening) Use half the usual morning dose at the predawn meal (Suhur) and the full dose at the sunset meal (Iftar), e. g. , glibenclamide 2. 5 mg or gliclazide 40 mg in the morning, glibenclamide 5 mg or gliclazide 80 mg in evening This presentation is a part of More on Islam presentation series. For other titles please contact moreonislam@hotmail. com

Recommended changes of treatment regimen in patients on insulin therapy who fast during Ramadan Before Ramadan During Ramadan Patients on insulin Ensure adequate fluid intake 70/30 premixed insulin twice daily, e. g. , 30 units in morning and 20 units in evening Use the usual morning dose at the sunset meal (Iftar) and half the usual evening dose at predawn (Suhur), e. g. , 70/30 premixed insulin, 30 units in evening and 10 units in morning; also consider changing to glargine or detemir plus lispro or aspart This presentation is a part of More on Islam presentation series. For other titles please contact moreonislam@hotmail. com

Algrithm for premixed insuling titration during Ramadan Fasting pre-Iftar Insulin adjustment Pre-Sahaur BG (mg/dl) of daily dose 300 20% 180 10% 100 -180 No change <100 or symptoms 10% 70 mg/dl 20% <50 mg/dl 30 -40% This presentation is a part of More on Islam presentation series. For other titles please contact moreonislam@hotmail. com

Recommended changes of treatment regimen in patients on insulin therapy who fast during Ramadan Before Ramadan During Ramadan Patients on insulin Reduce total insulin dose 70% glargin and rapid 60% as glargin acting insulin 40% as rapid-acting Before Iftar and Sahur This presentation is a part of More on Islam presentation series. For other titles please contact moreonislam@hotmail. com

Insulin regimen adjustments in people with type 2 diabetes who are fasting for Ramadan Regimen Suggested adjustments Single basal (or premixed) Insulin Take insulin before dinner (Iftar) Empirical reduction of dose by 30% (if blood glucose is well controlled pre-Ramadan) Adjust dose as per home blood glucose monitoring to avoid daytime (especially late in the day/pre-Iftar) hypoglycemia Twice daily premixed (or basal) insulin Take the usual larger dose at Iftar Reduce the smaller dose (usually before dinner) by 30% to coincide with pre-Suhur/early morning meal Adjust doses to avoid early morning and pre-sunset hypoglycemia Twice daily premixed insulin plus bolus insulin before lunch Take the usual larger dose at Iftar Omit the bolus dose unless the patient’s eating profile includes a large meal at midnight Basal-bolus insulin Basal insulin to be taken pre-Iftar without dose change Bolus dose taken before Iftar may need to be augmented Bolus dose taken before Suhur is either omitted or reduced to avoid daytime Hypoglycemia Premeal boluses Adjust the pre-Iftar dose to avoid postprandial hyperglycemia Adjust the pre-Suhur dose to avoid daytime Hypoglycemia This presentation is a part of More on Islam presentation series. For other titles please contact moreonislam@hotmail. com

Recommendations for prevention of hypoglycaemia during Ramadan • Blood glucose monitoring • Record blood glucose to determine pattern of hypoglycaemia • Medication adjustment (1 -2 month before) • Avoid skipping Sahur meals • Avoid strenuous physical activity during fasting • Breaking fast if there is hypoglycaemia This presentation is a part of More on Islam presentation series. For other titles please contact moreonislam@hotmail. com

When to break the fast IDF, Diabetes and Ramadan: Practical Guidelines, April 2016 This presentation is a part of More on Islam presentation series. For other titles please contact moreonislam@hotmail. com

Self monitoring of blood glucose • Essential for safe fasting • Glucose monitoring is useful for: o Meal planning to avoid hypoglycemia and dehydration during prolonged fasting hours o Appropriate meal choice to avoid postprandial hyperglycemia 3. Nutritional considerations 4. Case study 5. Diabetes education AL-Arouj M et al. Diabetes Care 2010; 33: 1895 -1902. This presentation is a part of More on Islam presentation series. For other titles please contact moreonislam@hotmail. com

Recommended timings to check blood glucose levels during Ramadan fasting IDF, Diabetes and Ramadan: Practical Guidelines, April 2016 This presentation is a part of More on Islam presentation series. For other titles please contact moreonislam@hotmail. com

Conclusion v. With the worldwide prevalence of diabetes increasing, and the number of fasting Muslims set to rise, the importance of effective guidelines for the management of diabetes during Ramadan fasting is clear. v. There is a paucity of evidence-based medicine in the field of diabetes management during Ramadan. Indeed, many recommendations are based on expert opinion rather than clinical evidence. v. Pre-Ramadan education has been shown to reduce the incidence of hypoglycaemia. However, guidance given by medical professionals, particularly in Muslim-minority countries, may be suboptimal. v. Different medications to treat diabetes have varying levels of hypoglycaemic risk, and Ramadan-specific treatment regimens including dose and/or timing adjustments should be produced for each patient. IDF, Diabetes and Ramadan: Practical Guidelines, April 2016 This presentation is a part of More on Islam presentation series. For other titles please contact moreonislam@hotmail. com

Conclusion • Diabetics with complications and those who are high risk should not fast • Diabetics must visit the physician at least one month prior to Ramadan • Only those with appropriate diets and physical activity, having controlled diabetes could fast during Ramadan • Patient education must be conducted before entering Ramadan • Management of diabetics in Ramadan is a good example of “Patient Centered Care (PCC)”. • Appropriate self management is the key to Ramadan fasting for diabetics. This presentation is a part of More on Islam presentation series. For other titles please contact moreonislam@hotmail. com

This presentation is a part of More on Islam presentation series. For other titles please contact moreonislam@hotmail. com

Targets of Ramadan-focused diabetes education IDF, Diabetes and Ramadan: Practical Guidelines, April 2016 This presentation is a part of More on Islam presentation series. For other titles please contact moreonislam@hotmail. com