Month of Ramadan

‫بسم هللا الرحمن الرحيم‬ ‫ياأيها ألذين أمنوا كتب عليكم ألصيام كما كتب على ألذين من قبلكم أيام‬ ‫معدودات فمن شهد منكم الشهر فليصمه و من كان منكم مريضا أو على سفر‬ ‫فعدة من أيام أخر يريد هللا بكم اليسر و ال يريد بكم العسر‪.‬‬ ‫صدق هللا العظيم‬

Ramadan Fasting and Diabetes: Risks, Benefits and Guidelines Ragab B. Roaeid

Introduction: Ramadan fasting requires abstaining from food and drink from sunrise to sunset. The length of the fast vary between seasons.

Physiology of fasting: In the fed state our body utilizes carbohydrates for the production of energy. During fasting lipids becomes the major source of energy. However, small amounts of glucose are essential. Organs like brain and RBCs which can not store glucose need constant supply of glucose that is provided by glycogenolysis and gluconeogensis. Unfortunately glucose stores in our body are limited.

During fasting the scenario changes as follows 1- Insulin levels are very low

2- Counter regulatory hormones are increased 3- Increased lipolysis with release of FFA 4- Increased formation of KB 5- The brain can not use FFA but utilizes KB Gluconeogenesis proceeds yet it provides small amount glucose.

6- Changes in water, electrolytes, urea, creatinine, and plasma osmolality.

In diabetes, these changes are worse.

Insulin deficiency (T1DM) or defective action (T2DM) make diabetics more vulnerable to: a) Increased rate of lipolysis and KB formation and in case of insulin deficiency the utilization of these fuel substrates is impaired.

b) The response to hypoglycemia will be hindered due i) Low stores of liver and muscle glycogen ii) Hypoglycemia unawareness iii) The role of Leptin C) Water and electrolyte losses lead to dehydration. i) Osmotic diuresis ii) Lack of insulin ** the changes are observed in water, electrolytes, U,Cr and osmolality occurred in both active and sedentary persons and are worse in the later.

Risks of fasting in diabetics: The earlier forms of diabetes treatment were food restriction and exercise.

In the fasting diabetic, serious complications may occur, these include: 1- Hypoglycemia 2- DKA 3- Marked hyperglycemia without DKA 4- Water and electrolyte disturbances It is worth noting that these complications varied in different studies.

Very critical questions facing us are, can my patient fast? If so what knowledge should I deliver to him?

Should I adjust the dose?

a) Very high risk patients; Severe hypo. Within the last 3m prior to Ramadan Patients with recurrent hypoglycemia Patients with hypoglycemia unawareness Patients with sustained poor glycemic control DKA with in the last 3m prior to Ramadan Type 1 diabetes patients Acute illness Pregnancy Patients on chronic dialysis

b) High risk patients; Patients with moderate hyperglycemia (average G150-300mg/dl or HbA1C 7.59.0%) Patients with renal insufficiency Patients with advanced macrovascular complications People living alone treated with insulin or SU Old age, Ill health and those on drugs affecting the mentation

C) Moderate risk: well controlled patients on Glenides D) Low risk: well controlled patients on diet alone

Benefits of Ramadan fasting: The benefit of Ramadan fasting are controversal. Some studies showed some improvement in metabolic control others did not. In the EPIDIAR study the frequencies of acute metabolic complications were more frequent in Ramadan than in non-Ramadan month.

In most of the studies the number of patients was small and most of them were well controlled.

Retinal vein thrombosis was reported to be increased during Ramadan in diabetics.

However, the incidence of stroke did not.

Incidence of acute complications during Ramadan at BDC: The attendance rate was lower during Ramadan by (35%).

The incidence of acute complications was higher in Ramadan

4.5% vs 2.3% during non-Ramadan.

During 2004 Total patients: 78

Hyperglycemia: 59 (75.6%) Hypoglycemia: 14 (17.9%) DKA: 5 (6.4%)

During 2007 155 133 (85.8%) 18 (11.6%) 4 (2.6%)

In both studies the most frequent ppt factor was neglecting Sohour dose in 70% of patients.

Poor food intake and increasing drug dosage was the most frequent ppt factor in those with hypoglycemia.

It seems likely that: 1- Health education was poor 2- patient selection was bad 3- Dosage adjustments were inappropriate Guidelines during Ramadan: 1- Those who are well controlled can reduce their dosage by 25% 2- The dose is to be divided in to 80% at Foutor and 20% at Souhor 3- In case of insulin treatment it should be 50% soluble+50%intermediate both at souhor and foutor.

4- Insulin glargin if available and supplemented with soluble insulin or rapid acting insulin at souhr and foutor may be more appropriate.

5- An other method is to give soluble insulin at foutor and soluble+intermediate at souhor.

6- Glenides carry less risk of hypo and can be given if available.

‫كل العام و انتم بخير‬ ‫‪Thank You‬‬