Comprehensive New Guidelines Address Diabetes and Ramadan

Miriam E Tucker

May 10, 2016

New guidelines from the International Diabetes Federation are the most comprehensive to date to address diabetes and Ramadan, including religious as well as medical guidance.

Ramadan is an annual period of fasting, prayer, and giving to charity observed by more than one billion Muslims every year.

Available free on the IDF website, "Diabetes and Ramadan Practical Guidelines" was developed and written by the Diabetes and Ramadan (DAR) International Alliance, with 12 main authors and 20 coauthors from all around the world.

"It is quite comprehensive, for many reasons.…One of the beautiful things is it's the first to include a religious opinion," Mohamed Hassanein, MBChB, chair of the DAR alliance and senior endocrinologist at Dubai Hospital, United Arab Emirates, told Medscape Medical News.

During the holy month of Ramadan, practicing Muslims fast from dawn to dusk. Depending on the time of year — which varies — and the geographic location, this can mean up to 20 hours of fasting a day. This year, Ramadan starts in early June.

Exemptions are granted for people with health conditions such as diabetes, for whom fasting can lead to hypoglycemia, hyperglycemia, dehydration, and diabetic ketoacidosis (DKA). However, the risk is greater for some people with diabetes than others, and these new guidelines provide risk stratification as well as management guidelines for those who do choose to fast.

Decision to Fast Must Be Made on Individual Basis

"The decision about whether to fast should be made on an individual basis in consultation with the patient's treating physician, taking into account the severity of illness and the level of risk involved," the authors write.

The number of people with diabetes in the Middle East and Africa — two regions with high numbers of Muslim inhabitants — is predicted to more than double by 2040. Currently, an estimated 148 million Muslims are living with diabetes worldwide.

"Many are quite passionate to fast," said Dr Hassanein, also an honorary senior lecturer at Cardiff University, United Kingdom, "so we try to guide them on a scientific basis, based on the medical condition [and] how risky it is….We want harmony between medical expertise and religious opinion."

The largely evidence-based document covers risk stratification of diabetes patients prior to Ramadan, pre-Ramadan education, a mobile- and web-based nutrition plan (for sunset to dawn), and medication adjustment during the holy month, with evidence included for all the major classes of glucose-lowering drugs.

An appendix provides a summary of the opinion of Prof Sawky Ibrahim Allam, mufti of the Arab Republic of Egypt, approving the guidelines.

Among other things, the mufti states, "If it is confirmed that fast will cause harm to the diabetics…the patient should obey the physician and break the fast; otherwise he will be [a] sinner."

Risk Stratification: Green, Yellow, and Red Patients

The document risk stratifies patients into three risk categories: Green (moderate/low risk) includes people with well-controlled type 2 diabetes who either take no medications or only drugs that aren't associated with hypoglycemia (second-generation sulfonylureas and basal insulin are included). If these patients fast, they are advised to check their blood glucose levels regularly and adjust medication dose as per the guideline's recommendations.

Patients falling into the higher-risk "yellow" category are advised not to fast, but exceptions can be made. Included in this category are type 2 patients in poor control and type 1 patients who are well-controlled, pregnant women with type 2 or gestational diabetes, and those with stage 3 chronic kidney disease.

In contrast, those in the highest "red" risk level are absolutely advised not to fast. These include patients with either severe hypoglycemia or DKA within the 3 months prior to Ramadan, a history of hypoglycemic unawareness, poorly controlled type 1 diabetes, or advanced macrovascular complications.

Patients in either the yellow or red categories who insist on fasting should be counseled to receive structured education, be followed by a qualified diabetes team, and check blood glucose regularly. Importantly, those patients must be prepared to break the fast in the case of hypo- or hyperglycemia or worsening of other medical conditions.

The risk categories and the mufti's opinion are available in Arabic as well as English. "The document actually works as a reference for anyone with interest on the topic," Dr Hassanein said.

The document was funded by an unrestricted educational grant from Sanofi Middle East, but the authors received no fees in connection with its development. Dr Hassanein has served as an advisor or consultant for AstraZeneca, Eli Lilly, Janssen, and Novo Nordisk and has served as a speaker or a member of a speaker's bureau for AstraZeneca, Eli Lilly, Janssen, Novo Nordisk, and Servier.

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