Recommendations for management of diabetes during Ramadan: update 2020, applying the principles of the ADA/EASD consensus

Abstract

Fasting the Holy month of Ramadan constitutes one of the five pillars of the Muslim faith. Although there is some evidence that intermittent fasting during Ramadan may be of benefit in losing weight and cardiometabolic risk factors, there is no strong evidence these benefits apply to people with diabetes. The American Diabetes Association/European Association for the Study of Diabetes consensus recommendations emphasize the importance of patient factors and comorbidities when choosing diabetes medications including the presence of comorbidities, atherosclerotic cardiovascular disease, heart failure, chronic kidney disease, hypoglycemia risk, weight issues and costs. Structured education and pre-Ramadan counseing are key components to successful management of patients with diabetes. These should cover important aspects like glycemic targets, self-monitoring of blood glucose, diet, physical activity including Taraweeh prayers, medication and dose adjustment, side effects and when to break the fast. The decision cycle adapted for the specific situation of Ramadan provides an aid for such an assessment. Children with type 1 diabetes should strongly be advised not to fast due to the high risk of acute complications such as hypoglycemia and probably diabetic ketoacidosis (DKA), although there is very little evidence that DKA is increased in Ramadan. Pregnant women with diabetes or gestational diabetes should be advised to avoid fasting because of possible negative maternal and fetal outcomes. Hypoglycemia is a common concern during Ramadan fasting. To prevent hypoglycemic and hyperglycemic events, we recommend the adoption of diabetes self-management education and support principles. The use of the emerging technology and continuous glucose monitoring during Ramadan could help to recognize hypoglycemic and hyperglycemic complications related to omission and/or medication adjustment during fasting; however, the cost represents a significant barrier.

Ramadan and Diabetes: A Narrative Review and Practice Update

“…On the back of this study, the American Diabetes Association (ADA) published their first recommendation for the management of diabetes in 2005 [42]. The publication was pioneering, and the recommendations have been widely adopted across the globe and reproduced in subsequent and more recent national and independent guidelines [43][44][45][46][47]. It is important that we acknowledge that whilst the EPIDIAR study has been fundamental in shaping guidance on fasting and Ramadan, it was conducted in the early 2000s in Asian and Middle Eastern countries where access to health services and the latest diagnostic, monitoring treatment options for diabetes were limited.…”

“…The findings of CREED were used to update the 2010 iteration of the ADA recommendations for diabetes in Ramadan [43]. More recent updates from CREED have impacted on recent guidance [47,48].…”

Recommendations for Ramadan fasting to patients with cardiovascular diseases; Turkish Society of Cardiology consensus report

“…Ramadan fasting is a form of intermittent fasting where the eating pattern shifts to a nocturnal eating pattern, but the major limitation of Ramadan fasting involves the complete restriction of fluid intake including water during the fasting period. Intermittent fasting has positive effects on insulin resistance and cardiovascular risk markers (7,8).…”

Diabetes und Migration

“…In Anbetracht der Gefahr einer euglykämischen diabetischen Ketoazidose ist jedoch bei Insulinmangel Vorsicht geboten [40]. Keton Messungen sind erforderlich bei Unwohlsein für alle Patienten die sich für das Fasten entscheiden und einer SGLT2-Hemmer Therapie unterliegen [41]. Bei unklaren Symptomen der Blutzuckerentgleisung (unklarer Differenzierung zwischen Unter-bzw.…”