2. The Holy Quran,
Surah Al Baqarah 2:185
– “Ramadan is the (month) in which was sent down the
Quran, as a guide to mankind, also clear (Signs) for
guidance and judgment (between right and wrong). So
every one of you who is present (at his home) during
that month should spend it in fasting, but if any one is
ill, or on a journey, the prescribed period (should be
made up) by days later. Allah intends every facility for
you; He does not want to put to difficulties. (He
wants you) to complete the prescribed period, and to
glorify Him in that He has guided you; and perchance
ye shall be grateful.”
3. Islam and Ramadan
Islam has 1.57 billion adherents
– 23% of the world population of 6.8 billion
– Growing by ~3% per year
Fasting during Ramadan, a holy month of Islam, is a duty
for all healthy adult Muslims
Muslims who fast during Ramadan must abstain from
eating, drinking, use of oral medications, and smoking
from pre-dawn to after sunset; however, there are no
restrictions on food or fluid intake between sunset and
dawn
4. Islam and Ramadan
Many patients with diabetes insist on fasting during
Ramadan, thereby creating a medical challenge for
themselves and their health care providers
It is important that medical professionals
be aware of potential risks associated with
fasting during Ramadan and with
approaches to mitigate those risks
5. From Fed state to Fasting state
The transition from a fed to a fasted state can be divided
into three stages:
– The postabsorptive phase, 6–24 h after beginning fasting
– The gluconeogenic phase, from 2–10 days of fasting
– The protein conservation phase, beyond 10 days of fasting
6. RISKS ASSOCIATED WITH FASTING IN
PATIENTS WITH DIABETES
Major risks associated with fasting
in patients with diabetes
•Hypoglycemia
•Hyperglycemia
•Diabetic ketoacidosis
•Dehydration and thrombosis
7. Categories of risk in patients with type 1 or
type 2 diabetes who fast during Ramadan
Very high risk High risk Moderate risk
•Severe hypoglycemia within •Moderate hyperglycemia •Well-controlled diabetes
the 3 months prior to Ramadan (average blood glucose 150– treated with short-acting insulin
•A history of recurrent 300 mg/dl or A1C 7.5–9.0%) secretagogues
hypoglycemia •Renal insufficiency
•Hypoglycemia unawareness •Advanced macrovascular
•Sustained poor glycemic complications Low risk
control •Living alone and treated with
•Ketoacidosis within the 3 insulin or sulfonylureas •Well-controlled diabetes
months prior to Ramadan •Patients with comorbid treated with lifestyle therapy,
•Type 1 diabetes conditions that present metformin, acarbose,
•Acute illness additional risk factors thiazolidinediones, and/or
•Hyperosmolar hyperglycemic •Old age with ill health incretin-based therapies in
coma within the previous 3 •Treatment with drugs that may otherwise healthy patients
months affect mentation
•Performing intense physical
labor
•Pregnancy
•Chronic dialysis
9. The bulk of literature indicates that fasting in
Ramadan is safe for the majority of type 2
diabetic patients with proper education and
diabetic management.
10. The physiological state of diabetics during
Ramadan
1. Carbohydrate metabolism in healthy persons
Most of the studies show slight decrease in serum glucose to
3.3 mmol to 3.9 mmol (60 mg/dl to 70 mg/dl) occurs in
normal adults a few hours after fasting has begun.
Changes in serum glucose may occur in individuals
depending upon food habits and individual differences in
metabolism and energy regulation.
11. The physiological state of diabetics
during Ramadan
2.Body weight
Weight losses of 1.7-3.8 kg have been reported
in normal weight individuals after they have
fasted for the month of Ramadan. (1-4)
Some studies also show no change or slight
increase.
12. The physiological state of diabetics
during Ramadan
3.Blood glucose variations in patients with diabetes
Most patients show no significant change in their glucose
control.
In some patients, serum glucose concentration may fall or
rise.
This variation may be due to the amount or type of food
consumption, regularity of taking medications, engorging
after the fast is broken, or decreased physical activities.
13. The physiological state of diabetics during
Ramadan
HbAIC values show no change or even
improvement during Ramadan. Only two studies
have reported slight increases in glycated
hemoglobin levels. (1-3)
The amount of fructosamine , insulin, C-peptide
also has been reported to have no significant
change before and during Ramadan fasting.(4-5)
14. Major risks associated with fasting in
patients with diabetes
Hypoglycemia
Hyperglycemia
Diabetic ketoacidosis
Dehydration and
thrombosis
DIABETES CARE, VOLUME 28, NUMBER 9 SEPTEMBER 2005
15. Risks associated with fasting in patients
with diabetes
Hypoglycemia:
It has been estimated that hypoglycemia accounts for 2–4% of
mortality in patients with type 1 diabetes (much lesser with
type2).
The recent EPIDIAR study showed that fasting during Ramadan
increased the risk of severe hypoglycemia (4.7-fold in
patients with type 1 diabetes and 7.5-fold in patients with type 2
diabetes).
Diabetes Care 2004;27:2306–2311
16. Risks associated with fasting in patients
with diabetes
Hyperglycemia
The EPIDIAR study showed
5 fold increase in the incidence of severe
hyperglycemia (requiring hospitalization) in
patients with type 2 diabetes
3 fold increase in the incidence of severe
hyperglycemia with or without ketoacidosis
in patients with type 1 diabetes.
Diabetes Care 2004;27:2306–2311
17. Risks associated with fasting in
patients with diabetes
Diabetic ketoacidosis
Patients with diabetes, who fast during Ramadan, are at
increased risk for development of diabetic ketoacidosis,
particularly if poorly controlled before Ramadan.
The risk may further increase due to excessive reduction
of insulin dosage based on the assumption that food
intake is reduced during the month.
Diabetes Care 2004;27:2306–2311
18. Risks associated with fasting in patients
with diabetes
Dehydration and thrombosis
Reports have suggested an increased incidence of retinal
vein occlusion.
However, hospitalizations due to coronary events or stroke
were not increased during Ramadan
Limitation of fluid intake during the fast, especially if
prolonged, is a cause of dehydration.
In addition, hyperglycemia produces an osmotic diuresis,
further contributing to volume and electrolyte depletion
DIABETES CARE, VOLUME 33, NUMBER 8, AUGUST 2010
19. Patients with one or more of the following
are advised not to fast
Conditions related to diabetes:
- Advanced nephropathy Physiological conditions:
- Severe retinopathy - Pregnancy
- Autonomic neuropathy - Lactation
- Hypoglycemic unawareness
- Major macrovascular diseases
- Recent hyper-osmolar state or DKA
- Poorly controlled diabetes (Mean RBG> 300)
- Multiple insulin injections per day
Clinical Diabetes ( Middle East Edition)- Volume 3, Number 3, 2004
20. Patients with one or more of the following
are advised not to fast
Co-existing major medical conditions such as:
- Acute peptic ulcer
- Severe Pulmonary Tuberculosis
- Severe infection
- Severe bronchial asthma
- Recurrent stones formation
- Cancer with poor general condition
- Overt cardiovascular diseases (Recent MI)
- Severe psychiatric conditions
- Hepatic dysfunction (liver enzymes > 2 × ULN)
Clinical Diabetes ( Middle East Edition)- Volume 3, Number 3, 2004
21. The principles of Pre-Ramadan
considerations
(a) Physical well being assessment;
(b) assessment of metabolic control;
(c) adjustment of the diet protocol for Ramadan fasting;
(d) adjustment of the drug regimen (e.g. change long-acting
hypoglycemic drugs to short-acting drugs to prevent hypoglycemia);
(e) encouragement of continued proper physical activity;
(f) recognition of warning symptoms of dehydration,
hypoglycemia and other possible complications.
22. Recommendations during Ramadan
fasting
I. Nutrition and Ramadan fasting:
Abstain from the high-calorie and highly-
refined foods prepared during this month.
II. Physical activity and Ramadan fasting:
It has been shown that fasting does not
interfere with tolerance to exercise.
It is necessary to continue their usual
physical activity especially during non-fasting
periods Lancet. 1989; 1:1396
N Engl J Med. 1991; 325: 196-199.
23. Recommendations during Ramadan
fasting
III. Other health tips for reduction of
complications:
1. Implementation of the 3D Triangle of Ramadan -
-
drug regimen adjustment,
diet control and
daily activity -- as the three pillars for more
successful fasting during Ramadan.
24. Recommendations during Ramadan
fasting
2. Diabetic home management that consists of:
Monitoring home blood glucose especially for IDDM
patients
Checking urine for acetone (IDDM patients);
Measuring daily weights and informing physicians of
weight reduction (dehydration, low food intake, polyuria)
or weight increase (excessive calorie intake) above two
kilograms;
Recording daily diet intake (prevention of excessive and
very low energy consumption).
25. Recommendations during Ramadan
fasting
3. Education about warning symptoms of
dehydration, hypoglycemia and hyperglycemia.
4. Education about breaking fast as soon as any
complication or new harmful condition occurs.
5. Immediate medical help for diabetics who need
medical help quickly, rather than waiting for
medial assistance the next day.
26. Ramadan Education and Awareness in
Diabetes (READ) program for Muslims with
Type 2 diabetes who fast during Ramadan
Diabet. Med. 27, 327–331 (2010)
27. Benefits of Education & Counseling
according to the READ study
Diabet. Med. 27, 327–331 (2010)
28.
29. General considerations
Several important issues deserve special attention:
– Individualization
– Frequent monitoring of glycemia
– Nutrition
– Exercise
– Breaking the fast
31. Changes in treatment regimen
Before Ramadan During Ramadan
Patients on diet and exercise control No change needed (modify time and intensity
of exercise), adequate fluid intake
Ensure adequate fluid intake
Patients on oral hypoglycemic agents
Biguanide, metformin 500 mg three times a Metformin, 1,000 mg at the sunset meal (Iftar),
day, or sustained release metformin 500 mg at the predawn meal (Suhur)
(glucophage R)
No change needed
TZDs, pioglitazone or rosiglitazone once daily
Dose should be given before the sunset meal
Sulfonylureas once a day, e.g., glimepiride 4 (Iftar); adjust the dose based on the
mg daily, gliclazide MR 60 mg daily glycemic control and the risk of
hypoglycemia
Sulfonylureas twice a day, e.g., glibenclamide Use half the usual morning dose at the
5 mg or gliclazide 80 mg, twice a day 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.
DIABETES CARE, VOLUME 33, NUMBER 8, AUGUST 2010
32. Changes in treatment regimen
Before Ramadan During Ramadan
Patients on insulin
70/30 premixed insulin twice daily, e.g., Ensure adequate fluid intake
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 (Saher), 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
DIABETES CARE, VOLUME 33, NUMBER 8, AUGUST 2010
33. Management of patients with Type 1
Diabetes
Fasting at Ramadan carries a very high risk for people
with type 1 diabetes
Risk is particularly exacerbated in poorly controlled
patients and those with limited access to medical care,
hypoglycemic un-awareness, unstable glycemic control, or
recurrent hospitalizations
The risk is also very high in patients who are unwilling or
unable to monitor their blood glucose levels several times
daily
34. Management of type 1 diabetes
during Ramadan
If patients choose to fast against medical advice, it is
advantageous if they are on a basal bolus regime and are
familiar with carbohydrate counting.
A small study (n = 9) of patients with type 1 diabetes using
insulin glargine and insulin Lispro or aspart, divided in a 6 :
4 ratio of the total 24-h insulin dose, reported no episodes
of severe hypoglycaemia or diabetic ketoacidosis requiring
hospitalization, and the haemoglobin A1c remained stable
at the end of Ramadan.
35. Management of type 1 diabetes
during Ramadan
Insulin Lispro, as a short-acting component of the basal
bolus regimen, has been found to have a lower 2-h post-
prandial glucose level after the sunset meal (p = 0.026),
with less hypoglycaemia (p < 0.01), as compared to
regular human insulin when given with neutral protamine
hagedorn insulin in an open-label crossover study (n =
64).
36. Management of patients with Type 1
Diabetes
A recent small study with insulin glargine suggests the
relative safety and efficacy of this agent in 15 relatively
well-controlled patients with type 1 diabetes who fasted for
18 h and experienced a minimal decline in mean plasma
glucose from 125 to 93 mg/dl with only two episodes of
mild hypoglycemia Mucha GT et al. Diabetes Care, 2004.
Another study in patients with type 1 diabetes using insulin
glulisine, Lispro, or aspart instead of regular insulin in
combination with intermediate-acting insulin injected twice
a day led to improvement in postprandial glycemia and
was associated with fewer hypoglycemic events
Kadiri A et al. Diabetes Metab, 2001.
37. Management of patients with Type 1
Diabetes
Continuous subcutaneous insulin infusion (pump)
management is an appealing alternative strategy, but at a
substantially greater expense
Compared with those who did not fast during Ramadan,
patients with type 1 diabetes on insulin pump therapy who
fasted showed a slight improvement in A1C
Benbarka MM et al. Diabetes Technol Ther, 2010.
38. Management of patients with Type 2
Diabetes
Diet-controlled patients: In patients with type 2 diabetes
who are well controlled with lifestyle therapy alone, the risk
associated with fasting is quite low
Patients treated with oral agents: The choice of oral
agents should be individualized
– Metformin
– Glitazones
– Sulfonylureas
– Short-acting insulin secretagogues
– Incretin-based therapy
– α-Glucosidase inhibitors
39. DM type2 patients treated with insulin
Problems facing patients with type 2 diabetes who
administer insulin are similar to those with type 1 diabetes,
except that the incidence of hypoglycemia is less
Aim is to maintain necessary levels of basal insulin to
prevent fasting hyperglycemia
An effective strategy would be judicious use of
intermediate- or long-acting insulin preparations plus a
short-acting insulin administered before meals
40. DM type2 patients treated with insulin
Although hypoglycemia tends to be less frequent, it is still
a risk, especially in patients who have required insulin
therapy for a number of years or in whom insulin
deficiency predominates in the pathophysiology
Very elderly patients with type 2 diabetes may be at
especially high risk
41. DM type2 patients treated with insulin
Using one injection of a long-acting or intermediate-acting
insulin can provide adequate coverage in some patients
as long as the dosage is appropriately individualized
However, most patients will require rapid- or short-acting
insulin administered in combination with the basal insulin
at meals, particularly at the evening meal
42. DM type2 patients treated with insulin
In a recent study, premixed Lispro with neutral protamine
Lispro in a 50:50 ratio was used along the evening meal
and regular human insulin with NPH in a 30:70 ratio at the
early morning meal during Ramadan was compared with
regular human insulin at 30:70 twice daily
It was observed that changing to Lispro Mix 50 during
Ramadan resulted in improvement in glycaemic control
without increasing the incidence of hypoglycaemia.
Int J Clin Pract, July 2010, 64, 8, 1095–1099
44. Insulin Lispro Compared with Regular
Human Insulin During Ramadan
Study Design
Open-label, randomized, two-way crossover study; 2
weeks on each arm
67 patients (21 female, 43 male), mean age 31.8
years
Treated with Lispro immediately before meals plus
NPH immediately before meals for 2 weeks then with
regular human insulin 30 minutes before meals plus
NPH 30 minutes before meals for 2 weeks, or the
opposite sequence
Kadiri A et al. Diabetes Metab (Paris) 2001;27:482-6.
45. Lispro Compared with Regular Human
Insulin During Ramadan
Postprandial Blood Glucose
5
Blood glucose excursion (mmol/L)
4
* P = 0.026
3 *
2
1 Humalog
Regular insulin
0
Fasting 1-
1-h 2-
2-h
Postprandial time
Kadiri A et al. Diabetes Metab (Paris) 2001;27:482-6.
46. Lispro Compared with Regular
Human Insulin During Ramadan
Hypoglycemia by Time of Day
20
27 Insulin Lispro
Regular insulin
Episodes of hypoglycemia
15
27
12
10 11
5
5 5 4
3
2
0 0 0
0
Sunrise 2-h 6-h Sunset 2-h 6-h Sunrise
meal meal meal
Kadiri A et al. Diabetes Metab (Paris) 2001;27:482-6.
47. A comparison of insulin Lispro Mix25 and
human insulin 30/70 in the treatment of type 2
diabetes during Ramadan
Mattoo et al, Diabetes Research and Clinical Practice 59 (2003) 137/143
48. Influence of Insulin treatment on the quality of life during
Ramadan: Results from a multicentre study:3
Practical Diabetes International Supplement January/February 1998 Vo1.15 No.1
49. Recommended changes to treatment regimen in
patients with type 2 diabetes who fast during
Ramadan
50. Recommendations – Pregnancy
Muslim pregnant women are exempt from fasting during Ramadan
type 1,
type 2 or
Gestational
They should be strongly advised to not fast during Ramadan
These women constitute a high-risk group and their management
requires intensified care
Diabetes Care. 2005; 28 (9).
52. Monitoring Recommendations
Patients should monitor their blood glucose even during the
fast to recognize subclinical hypo and hyperglycemia
Islam allows diabetics to have regular blood test while
fasting
If blood glucose is noted to be low (<60mg/dl), the fast must
be broken
If blood glucose is noted to be (>300mg/dl), ketones in urine
should be checked & medical advice sought
53. Post-Ramadan supervision
The patients therapeutic regimen should be changed
back to its previous schedule.
Patients should also be required to get an overall
education about the impact of fasting on their physiology
Degenerative complications check up
Monthly weight, blood pressure, HbA1c and renal
function evaluation every six months.
Diabetes Care. 1997; 20:1925-1926.
54. Conclusion
Majority of uncomplicated type 2 diabetic patients can fast during
Ramadan safely
Pre-Ramadan medical assessment, education and motivation are
very important to prevent diabetic related complications
Islam allows diabetics to have regular blood test while fasting
Fasting along with regular prayer have been proved to aid in better
control of diabetes
Individualization and frequent monitoring of glycemia can
significantly reduced the major risks associated with fasting
However, the reduction in serum glucose ceases due to increased gluconeogenesis in the liver. That occurs because of a decrease in insulin concentration and a rise in glucagon and sympathetic activity .Ref:.Azizi F, Rasouli HA. Serum glucose, bilirubin, calcium, phosphorus, protein and albumin concentrations during Ramadan. Med J IR Iran. 1987; 1:38-41.
While no food or drink is consumed between dawn and sunset during the month of Ramadan, there is no restriction on the amount or type of food consumed at night. Furthermore, most diabetics reduce their daily activities during this period in fear of hypoglycemia. These factors may result in not only a lack of weight loss, but also a weight gain in such patients . Ref:Azizi F. Effect of dietary composition on fasting-induced changes in serum thyroid hormones and thyrotropin. Metabolism.1978; 27:934-945. (2) Sajid KM, Akhtar M, Malik GQ. Ramadan fasting and thyroid hormone profile. JPMA. 1991; 41:213-216. (3) Takruri HR. Effect of fasting in Ramadan on body weight. Saudi Med J. 1989; 10:491-494. (4) Sulimani RA. Effect of Ramadan fasting on thyroid function in healthy male individuals. Nutr Res. 1988; 8:549-552.(5) Rashed H. The fast of Ramadan: No problem for the well: the sick should avoid fasting. BMJ. 1992; 304:521-522. (6) Sulimani RA, Laajam M, Al-Attas O, Famuyiwa FO, Bashi S, Mekki MO. The effect of Ramadan fasting on diabetes control type II diabetic patients. Nutrition Research 1991; 11:261-264. (7) Laajam MA. Ramadan fasting and non insulin-dependent diabetes: Effect of metabolic control. East Afr Med J. 1990; 67:732-736. (8) Mafauzy M, Mohammed WB, Anum MY, Zulkifli A, Ruhani AH. A study of fasting diabetic patients during the month of Ramadan. Med J Malaya.1990; 45:14-17.
Ref:Dehghan M, Nafarabadi M, Navai L, Azizi F. Effect of Ramadan fasting on lipid and glucose concentrations in type II diabetic patients. Journal of the Faculty of Medicine, Shaheed Beheshti University of Medical Sciences, Tehran, I.R. Iran. 1994; 18:42-47. Bouguerra R, Ben Slama C, Belkadhi A, Jabrane H, Beltaifa L, Ben Rayana C, Doghri T. Metabolic control and plasma lipoprotein during Ramadan fasting in non-insulin dependent diabetes .Second International Congress on Health and Ramadan. Dec. 1-3, 1997, Istanbul, Turkey, P 33. Niazi G, Al Nasir F. The effect of Ramadan fasting on Bahraini patients with chronic disorders. Second International Congress on Health and Ramadan. Dec. 1-3, 1997, Istanbul, Turkey, P23Bagraicik N, Yumuk V, Damei T, Ozyazar M. The effect of fasting on blood glucose, fructosamine, insulin and C- peptide levels in Ramadan. First International Congress on Health and Ramadan. Jan. 19-22, 1994, Casablanca, Morocco, P 32.
Ref:Ewis A, Afifi NM. Ramadan fasting and non-insulin-dependent diabetes mellitus : Effect of regular exercise. Second International Congress on Health and Ramadan. Dec. 1-3, 1997, Istanbul,Turkey, P 76. (2) Al Nakhi A, Al Arouj M, Kandari A, Morad M. Multiple insulin injection during fasting Ramadan in IDDM patients. Second International Congress on Health and Ramadan. Dec. 1-3, 1997, Istanbul, Turkey, P 77. (3) Klocker N, Belkhadir J, El Ghomari H, Mikou A, Naciri M, Sabri M. Effects of extreme chrono-biological diet alternations during Ramadan on metabolism in NIDDM diabetes with oral treatment. Second International Congress on Health and Ramadan. Dec. 1-3, 1997, Istanbul, Turkey,(4) Sulimani RA, Laajam M, Al-Attas O, Famuyiwa FO, Bashi S, Mekki MO. The effect of Ramadan fasting on diabetes control type II diabetic patients. Nutrition Research 1991; 11:261-264. (5) Laajam MA. Ramadan fasting and non insulin-dependent diabetes: Effect of metabolic control. East Afr Med J. 1990; 67:732-736.
Ref: 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;27:2306–2311
Hyperglycemia may have been due to excessive reduction in dosages of medications to prevent hypoglycemia.Patients who reported an increase in food and/or sugar intake had significantly higher rates of severe hyperglycemia.Ref: 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;27:2306–2311
Ref: 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;27:2306–2311
Orthostatic hypotension may develop, especially in patients with preexisting autonomic neuropathy. Syncope, falls, injuries, and bone fractures may result from hypovolemia and the associated hypotension.In addition, contraction of the intravascular space can further exacerbate the hypercoagulable state that is well demonstrated in diabetes. Increased blood viscosity secondary to dehydration may enhance the risk of thrombosis and stroke.Ref:Beckman JA, Creager MA, Libby P. Diabetes and atherosclerosis: epidemiology, pathophysiology, and management. JAMA 2002;287:2570–2581Akhan G, Kutluhan S, Koyuncuoglu HR.Is there any change in stroke incidence during Ramadan? Acta Neurol Scandin 2000;101:259–261Alghadyan AA. Retinal vein occlusion in Saudi Arabia: possible role of dehydration. Ann Ophthalmol 1993;25:394–398
Dietary indiscretion during the non-fasting period with excessive gorging, or compensatory eating, of carbohydrate and fatty foods contributes to the tendency towards hyperglycemia and weight gain. It has been emphasized that Ramadan fasting benefits appear only in patients who maintain their appropriate diets.Ref: Tang C, Rolfe M. Clinical problems during fast of Ramadan. Lancet. 1989; 1:1396Several studies indicate that light to moderate regular exercise during Ramadan fasting is harmless for NIDDM patients.Ref: Horton ES. Exercise and decreased risk of NIDDM. N Engl J Med. 1991; 325: 196-199.
As the insulin requirement decreased by 28% from baseline (p = 0.002), it has been suggested that insulin should be reduced by 70% of the pre-Ramadan doses during the fastRef: Insulin therapy during Ramadan fast for patients with type 1 diabetes mellitus. J Med Liban 2008; 56: 46.
Ref: Treatment of type 1 diabetes with insulin Lispro during Ramadan. Diabetes Metab 2001; 27: 482–486.
Hypoglycemia episodes and weight gain were similar in both the groups.
Pregnancy is a state of increased insulin resistance and insulin secretion and of reduced hepatic insulin extraction. Fasting glucose concentrations are lower but postprandial glucose and insulin levels substantially higher in healthy pregnant women than those who are not pregnant. Elevated blood glucose and A1C levels in pregnancy are associated with increased risk for major congenital malformations. Fasting during pregnancy would be expected to carry a high risk of morbidity and mortality to the fetus and mother, although controversy exists (28). While pregnant Muslim women are exempt from fasting during Ramadan, some with known diabetes (type 1, type 2, or gestational) insist on fasting during Ramadan. These women constitute a high-risk group, and their management requires intensive care (29). In general, women with pregestational or gestational diabetes should be strongly advised to not fast during Ramadan. However, if they insist on fasting, then special attention should be given to their care. Pre-Ramadan evaluation of their medical condition is essential. This includes preconception care with emphasis on achieving near-normal blood glucose and A1C values, counseling about maternal and fetal complications associated with poor glycemic control, and education focused on self-management skills. Ideally, patients should be managed in high-risk clinics staffed by an obstetrician, diabetologists, a nutritionist, and diabetes nurse educators. The management of pregnant patients during Ramadanis based on an appropriate diet and intensive insulin therapy. The issues discussed above concerning the management of type 1 and type 2 diabetes alsoapply to this group, with the exception that more frequent monitoring and insulin dose adjustment is necessary.
Ref: Omar M, Motala A. Fasting in Ramadan and the diabetic patient. Diabetes Care. 1997; 20:1925-1926.