Diabetes and Ramadhan

Dr Ayesha Farooq
Ahsaas.
Diabetes Demographics:
 Global pandemic of obesity leading to Diabetes.
 537 million adults (20-79 years) are living with diabetes - 1 in 10.
 Predicted to rise to 643 million by 2030 and 783 million by 2045.
 Over 3 in 4 adults with diabetes live in low- and middle-income countries.
 Pakistan is one of the most vulnerable countries to diabetes-related deaths.
 Diabetes is responsible for 6.7 million deaths in 2021 - 1 every 5 seconds.
 Diabetes caused at least USD 966 billion dollars in health expenditure – a 316%
increase over the last 15 years.
 541 million adults have Impaired Glucose Tolerance (IGT), (Prediabetes) which
places them at high risk of type 2 diabetes.
 Muslims with DM world wide 150 million.
 Fasting 120 Millions.
Prevalence:

Country Prevalence of diabetes (%)

Pakistan 30.8
French Polynesia 25.2
Kuwait 24.9
New Caledonia 23.4
Northern Mariana Islands 23.4
Nauru 23.4
The Marshall Islands 23.0
Mauritius 22.6
Kiribati 22.1
Egypt 20.9
Pakistan ranks 3rd to 1st in the world in diabetes
prevalence after China and India
What is Diabetes:

It is a disorder of carbohydrate metabolism in which blood glucose level is

chronically high due to insulin's impaired secretion or action.
It has two types:
type 1, which occurs in childhood and is usually mediated by immune
mechanisms,
type 2, which occurs later in life, particularly with advancing age due to
diseases of the pancreas.
Video
Factors that predispose to develop
diabetes :
 genetics
 sedentary lifestyle
 food with higher sugar content.
 canned and highly processed food
 obesity was 57.9% (42% in males and 58% in females), and central
obesity was 73.1% (37.3% in males and 62.7% in females) in Pakistan .
 no physical activity (children to diabetes in the years to come).
 The incidence of diabetes was also found to be significantly more in
urban areas (15.1%) as compared to rural areas (1.6%).
 Dislocation of people to urban areas from rural areas coupled with the
adaptation to the urban sedentary way of life in Pakistan makes the
possible increase in the number of cases even more concerning
Complications:

 Infections ,UTI. Skin.

 cardiac-related deaths,
 Blindness,
 Renal failure,
 Depression/ Suicide .
 Amputations of the diabetic foot have also become increasingly common
with the advancing stages of the disease.
According to a study carried out in China chronic
complications of diabetes were:
Fasting and Diabetes:

 Despite the advice ‘not-to-fast’, a significant number of patients do fast.

 We recognize that fasting is a personal choice and if a person chooses
to fast despite advice to the contrary, he/she should be adequately
supported and monitored closely
 Monitor Ramadan and for a brief period thereafter.
 Pre-Ramadan assessment is crucial to ensure a safe Ramadan
experience.
PATHOPHYSIOLOGY OF FASTING
 Pancreas release Insulin according to demand, which promotes the storage
of glucose in liver and muscle as glycogen, is stimulated by feeding in
healthy individuals.
 During fasting, circulating glucose levels tend to fall, leading to decreased
secretion of insulin. Concurrently, levels of glucagon and catecholamine
rise, stimulating the breakdown of glycogen, and at the same time
gluconeogenesis is augmented .
 As fasting becomes protracted for more than several hours, glycogen
stores become depleted, and the low levels of circulating insulin allow
increased fatty acid release from adipocytes (stored fat).
 Oxidation of fatty acids generates ketones that can be used as fuel by
skeletal and cardiac muscle, liver, kidney, and adipose tissue, thus sparing
glucose for continued utilization by brain and erythrocytes.
Plan for diabetic for fasting:

This may include:

 Checking your blood sugar levels more often than you normally
would and making sure you have enough test strips to do this. Checking
your blood sugar levels does not break the fast, but you must break
the fast if your blood sugars are too high or too low.
 What to do if your blood sugar is too low or too high, or if you become
unwell (Sick Day rules).
 Adjustments to your diabetes tablets, you may need a different
type, or dose and need to know the best time to take them.
 Adjustments to your insulin. You won’t need as much insulin before
the start of the fast. Also, the type of insulin may need changing from
your usual type. Remember, pre-mixed insulin is not recommended
during fasting.
3 Categories
Red Zone not to fast:
 Severe hypoglycemia within the 3 months prior to Ramadan b
 DKA within the 3 months prior to Ramadan
 Hyperosmolar hyperglycemic coma within the 3 months prior to
Ramadan
 History of recurrent hypoglycemia
 History of hypoglycemia unawareness
 Poorly controlled T1DM
 Acute illness
 Pregnancy in pre-existing diabetes or GDM treated with insulin
 Chronic dialysis or CKD stage 4 & 5
 Advanced macro vascular complications
 Old age with ill health
 Type 2 diabetes requiring insulin (MDI or mixed insulin) with no prior
experience of safe fasting
One or more of the following for moderate risk:

 T2DM with sustained poor glycemic control .

 Well-controlled T1DM
 Well-controlled T2DM on MDI or mixed insulin
 Pregnant T2DM or GDM controlled by diet only or metformin.
 CKD stage 3
 Stable macrovascular complications.
 Patients with comorbid conditions that present additional risk factors
 People with diabetes performing intense physical labour.
 Treatment with drugs that may affect cognitive function.
 Type 2 diabetes on SGLT-2 inhibitors (consider alternatives/stopping)
Well-controlled T2DM treated with one or more of
the following can Fast:

 Lifestyle therapy
 Metformin
 Acarbose
 Thiazolidinediones
 Second-generation SUs (moderate risk, regular SMBG advised)
 Incretin-based therapy (DPP-4 inhibitors or GLP-1 RAs)
 SGLT-2 inhibitors
 Basal Insulin (moderate risk, regular SMBG advised)
Consult Dr :

 First time fasting with DM or insulin.

 Any chronic illness. Co-morbidity CVS ,CKD, Infection.
 Any acute illness on top of chronic. UTI, Chest infection.
 Prior experience of fasting with this illness.
 New complications during year.
 Risk may be immediately obvious e.g. risk of dehydration with
persistent vomiting and diarrhea ,pregnancy.
One size does not fit all:
Tailoring.
Hypoglycemia

 For most people with diabetes, hypoglycemia is when your blood sugar
level is below 70 milligrams per deciliter (mg/dL) or 3.9 millimoles per
liter (mmol/L).

 For most people without diabetes, hypoglycemia is when your blood

sugar level is below 55 mg/dL or 3.1 mmol/L.

 Hypoglycemia requires immediate treatment by eating or drinking

sugar/carbohydrates. Severe hypoglycemia can be life-threatening and
requires treatment with emergency glucagon and/or medical
intervention.
Sign symptoms:

 Shaking or trembling.
 Weakness.
 Sweating and chills.
 Extreme hunger (polyphagia).
 Faster heart rate.
 Dizziness or lightheadedness.
 Confusion or trouble concentrating.
 Anxiety or irritability.
 Color draining from your skin (pallor).
 Tingling or numbness in your lips, tongue or cheeks.
Severe hypoglycemia

 Blurred or double vision.

 Slurred speech.
 Clumsiness or difficulty with coordination.
 Being disoriented.
 Seizures.
 Loss of consciousness.
 Severe hypoglycemia is life-threatening. It needs immediate medical
treatment. In rare cases, severe hypoglycemia that isn’t treated can
result in a coma and/or death.
Nocturnal Hypoglycemia.

Symptoms may include:

 Restless sleep.
 Sweating through your pajamas or sheets.
 Crying out during sleep.
 Having nightmares.
 Feeling tired, disoriented or confused after waking up
Chronic hyperglycaemia leading to
early Hypos.
 If your blood sugar is falling rapidly, you may experience symptoms
before this point.
 Some people with diabetes can have symptoms of hypoglycemia at
relatively higher glucose levels. This is because, when you have
chronic hyperglycemia (high blood sugar), your body gets used to
that as its “normal” level. It alters the set point at which low blood sugar
symptoms become apparent.
Hypoglycemia Unawareness:
 low blood sugar episodes don’t have symptoms or don’t notice them..
People with hypoglycemia unawareness are more likely to have severe
episodes and need medical help.
 Diabetics who live with chronically low blood sugar levels. Their body
stops having symptoms when low blood sugar occurs.
 Let your friends and family know so that they know how to help you if
you experience a severe low blood sugar episode.
 Using a continuous glucose monitoring (CGM) device that can alert
you when you have hypoglycemia.
 More frequent manual blood sugar checks.
 A service dog called a diabetes alert dog that’s specially trained to alert
you when you have low blood sugar
Other Complications:
 However acute cardiac illness in patients with Type 2 DM is not different during
Ramadan than at other times ,fasting metabolism take over.
 Blood pressure control improves,
 Significant improvement in HbA1c, Lipid profile, BMI, renal function, systolic and
diastolic blood pressure were not significantly altered.
 patients with stable CHD who were receiving optimal diabetes care, no adverse
cardiovascular effects were associated with Ramadan fasting.
Causes:
 Taking too much insulin, the wrong insulin or injecting it into your muscle
instead of in your fat tissue.
 Not timing insulin and carb intake correctly (for example, waiting too long to
eat a meal after taking insulin for the meal).
 Taking too much or too high of a dose of oral diabetes medications.
 Being more active than usual.
 Drinking alcohol without eating.
 Eating meals later than usual or skipping meals.
 Not balancing meals by including fat, protein and fiber.
 People who are pregnant and have Type 1 diabetes are also more likely to
experience low blood sugar during the first trimester due to hormone changes.
Treat with carbohydrates.

 The American Diabetes Association recommends the “15-15 rule” to

treat an episode of mild to moderate hypoglycemia:
 Eat or drink 15 grams of fast-acting carbs to raise your blood sugar.
 After 15 minutes, check your blood sugar.
 If it’s still below 70 mg/dL, have another 15 grams of fast-acting carbs.
 Repeat until your blood sugar is at least 70 mg/dL.
15,15 rule:

Some examples of foods that contain about 15 grams of fast-acting carbs include:

 1 small piece of fruit, such as half a banana.

 4 ounces (half-cup) of juice or regular soda (not diet).
 1 tablespoon of sugar, honey or syrup.
 1 tube of instant glucose gel (check the instructions).
 3 to 4 glucose tablets (check the instructions).
 If you have symptoms of hypoglycemia but can’t check your blood sugar, use the
15-15 rule until you feel better.

 Children may need fewer grams of carbs to treat hypoglycemia. Check with your
child’s healthcare provider.
How is severe hypoglycemia treated?
 Slurring their speech, disoriented or unconscious, don’t give them food or
liquid. They could choke.
 require the use of emergency glucagon. synthetic form of glucagon an
injection or nasal powder (dry nasal spray), depending on the type.
Synthetic glucagon triggers your liver to release stored glucose, which then
raises blood sugar.
 If the glucagon is injectable, inject it into their butt, arm or thigh, following
the instructions in the kit. If the glucagon is a nasal powder, follow the
instructions on the package to administer it into their nostril.
 When the person regains consciousness (usually in 5 to 15 minutes), they
may experience nausea and vomiting. If they’re laying down, roll them onto
their side to prevent choking in case they vomit.
 Don’t hesitate to call 911 for help. If someone is unconscious and glucagon
isn’t available or you don’t know how to use it, call 911 immediately.
Hyperglycaemia:

 This happens when your body has too little insulin (a hormone) or if your
body can’t use insulin properly (insulin resistance).
 If you have hyperglycemia that’s untreated for long periods of time, it
can damage your nerves, blood vessels, tissues and organs.

 Severe hyperglycemia can also lead to an acute (sudden and severe)

life-threatening complication called diabetes-related ketoacidosis (DKA),
especially in people with diabetes who take insulin or people with
undiagnosed Type 1 diabetes. This requires immediate medical
treatment.
Levels:
 For people undiagnosed with diabetes, hyperglycemia is blood glucose greater
than 125 mg/dL (milligrams per deciliter) while fasting (not eating for at least
eight hours).

 A person has prediabetes if their fasting blood glucose is 100 mg/dL to 125
mg/dL.

 A person with a fasting blood glucose greater than 125 mg/dL on more than
one occasion usually receives a diabetes diagnosis — typically Type 2 diabetes.
People with Type 1 diabetes usually have very high blood sugar (above 250
mg/dL) upon diagnosis.

 For a person with diabetes, hyperglycemia is usually considered to be a blood

glucose level greater than 180 mg/dL one to two hours after eating. But this
can vary depending on what your target blood sugar goals are.
Symptoms of long-term hyperglycemia include:

 Fatigue.
 Weight loss.
 Vaginal yeast infections.
 Skin infections.
 Slow-healing cuts and sores.
Levels:

 The glucose level at which people with diabetes start to experience

symptoms varies. Many people don’t experience symptoms until their
blood sugar is 250 mg/dL or higher. People who haven’t yet been
diagnosed with diabetes typically experience these symptoms at lower
levels.
If you’re experiencing symptoms of DKA, such as
high blood sugar with below go to the
emergency room. DKA requires immediate
medical treatment:

Symptoms include:

 Nausea and vomiting.

 Dehydration.
 Abdominal pain.
 Fruity-smelling breath.
 Deep labored breathing or hyperventilation (Kussmaul breathing).
 Rapid heartbeat.
 Confusion and disorientation.
 Loss of consciousness.
Healthy life with diabetes

 It’s important to know that you can live a healthy life with diabetes. The
following are key to a better prognosis:

 Lifestyle changes.
 Regular exercise.
 Dietary changes.
 Regular blood sugar monitoring, especially for those who take insulin.
 Studies have shown that people with diabetes may be able to reduce
the risk of complications by consistently keeping their A1C levels below
7%.
Challenges :

 Not all patients will consult HCPs prior to fasting

 Some patients prefer to discuss fasting with their local imam rather
than their physician.
 Disparity has existed between medical and religious advice on diabetes
and Ramadan fasting
Nutrition Advice:
Precautions you need to take

 Never leave home without medication, glucose treatment and some sort
of diabetes identification like a medical bracelet.
 Carry some dates, sugar, juice or anything that can raise your glucose
level in case you experience hypoglycemia and need to break your fast.
 Keep testing your blood glucose regularly - it will not break your fast.
 Always carry a bottle of water with you, in case you feel dehydrated. It is
safer to end your fast than to collapse or faint due to dehydration, one
of the symptoms of hyperglycemia.
 Do not stop your insulin but do alter your dose and times as advised by
your doctor
okay to exercise?

 Exercise is another good way to keep your glucose levels in check.

During Ramadan, it is best to do light or moderate exercise for at least
30 minutes between Iftar and Suhoor times only. Ensure that you are
always hydrated too. What’s more, even performing your Taraweeh
prayers can be included as part of your exercise regime.
People can also be exempt from fasting if they:

 are children (under the age of puberty)

 are elderly
 are sick or have a certain health condition
 have learning difficulties
 are travelling
 are pregnant, breastfeeding or menstruating.
For patients unable to fast, alternatives include

 Non-consecutive fasting.
 Fasting in winter months.
 Make up fasts after Ramadan.
 Paying in charity.
 Hadith about Massah and Qasr during travelling.