Practical Management of Type 2 Diabetes during the Holy month of Ramadan

1. Practical Management of Type 2 DiabetesPractical Management of Type 2 Diabetes
During the Holy Month of RamadanDuring the Holy Month of Ramadan
Prof. Md. Farid Uddin
Founder Chairman & Course-Coordinator
Department of Endocrinology
Bangabandhu Sheikh Mujib Medical University
Dhaka, Bangladesh
Email: dr.md.fariduddin@gmail.com
Web: www.endobsmmu.com

2. Diabetes & RamadanDiabetes & Ramadan
 Diabetes Mellitus is a chronic disease
 Fasting is one of the five pillars of Islam
 About 50 million people with Diabetes fast during
Ramadan
 Recent Advancements give us the opportunity to
offer the patients have a normal or near normal
life

3. Frequently asked questions during RamadanFrequently asked questions during Ramadan
 Can a diabetic patient fast?
 What are the risks & benefits associated with
fasting?
 What about diet and exercise?
 How to adjust drugs?
 Can a patient monitor blood sugar while fasting?

4. Can a diabetic patient fastCan a diabetic patient fast
during Ramadan?during Ramadan?

5. IslamiCity.com- Ramadan Fasting and DiabetesIslamiCity.com- Ramadan Fasting and Diabetes
MellitusMellitus
The bulk of literature indicates thatThe bulk of literature indicates that
fasting in Ramadan is safe for thefasting in Ramadan is safe for the
majority of diabetic patients, but…majority of diabetic patients, but…

6. Patient needs-Patient needs-
1.1. Pre-Ramadan assessmentPre-Ramadan assessment
2.2. Proper educationProper education
3.3. ManagementManagement

7. Physician’s Role?Physician’s Role?

8. Guidance and advice to allowGuidance and advice to allow
diabetic patients to fast as safely asdiabetic patients to fast as safely as
possiblepossible

9. Pre-Ramadan AssessmentPre-Ramadan Assessment
1.1. Assessment of glycemic statusAssessment of glycemic status
2.2. Assessment of complications &Assessment of complications &
co-morbid conditionsco-morbid conditions
3.3. Assessment of patient’s abilityAssessment of patient’s ability

10. Conditions related to diabetes:Conditions related to diabetes:
- Advanced nephropathy- Advanced nephropathy
- Severe retinopathy- Severe retinopathy
- Autonomic neuropathy- Autonomic neuropathy
- Hypoglycemic unawareness- Hypoglycemic unawareness
- Major macrovascular diseases- Major macrovascular diseases
- Recent hyper-osmolar state or DKA- Recent hyper-osmolar state or DKA
- Poorly controlled diabetes (Mean RBG> 300)- Poorly controlled diabetes (Mean RBG> 300)
- Multiple insulin injections per day- Multiple insulin injections per day
Patients with one or more of the followingPatients with one or more of the following
are advised not to fastare advised not to fast
Physiological conditions:Physiological conditions:
- Pregnancy- Pregnancy
- Lactation- Lactation
Clinical Diabetes ( Middle East Edition)- Volume 3, Number 3, 2004

11. Co-existing major medical conditions such as:Co-existing major medical conditions such as:
- Acute peptic ulcer- Acute peptic ulcer
- Severe Pulmonary Tuberculosis- Severe Pulmonary Tuberculosis
- Severe infection- Severe infection
- Severe bronchial asthma- Severe bronchial asthma
- Recurrent stones formation- Recurrent stones formation
- Cancer with poor general condition- Cancer with poor general condition
- Overt cardiovascular diseases (Recent MI)- Overt cardiovascular diseases (Recent MI)
- Severe psychiatric conditions- Severe psychiatric conditions
- Hepatic dysfunction (liver enzymes > 2 × ULN)- Hepatic dysfunction (liver enzymes > 2 × ULN)
Clinical Diabetes ( Middle East Edition)- Volume 3, Number 3, 2004
Patients with one or more of the followingPatients with one or more of the following
are advised not to fastare advised not to fast

12. Benefits associated with fastingBenefits associated with fasting

13. The Health Benefits of fastingThe Health Benefits of fasting
• Fasting improves metabolic function
• Helps to loose excess weight & water
• Better control of Hypertension
• Flush out toxins
• Strengthen immune system
Prescription for nutritional healing by James and Phyllis Blach, pp 548-550

14. General BenefitsGeneral Benefits

15. Patients should be advised to make
use of this opportunity to combine the
spiritual benefit with improvement in
the metabolic control of the diabetes
mainly through weight reduction.

16. Spiritual BenefitsSpiritual Benefits
Quran 2:183Quran 2:183
“ O you who believe! Fasting has been
prescribed to you as it was prescribed
to those before you so that you attain
Taqwa (self restraint , God Awareness)”

17. What are the risksWhat are the risks
associated with fasting?associated with fasting?

18. Major risks associated with fastingMajor risks associated with fasting
in patients with diabetesin patients with diabetes
 Hypoglycemia
 Hyperglycemia
 Dehydration
 Weight changes
DIABETES CARE, VOLUME 28, NUMBER 9 SEPTEMBER 2005

19. Special precautions are recommendedSpecial precautions are recommended
to avoid hypoglycemic eventsto avoid hypoglycemic events
 To take Suhur close to Suhur time
 To change in the schedule, amount and composition of
meals
 To reduce physical activity during the day time.
However physical exercise can be performed about one
hour after Iftar
 To keep the same calorie during Ramadan as before

20. Management of hyperglycemiaManagement of hyperglycemia
in type 2 diabetes while fastingin type 2 diabetes while fasting

21. IndividualizationIndividualization
• Care must be individualizedCare must be individualized
• The management plan will differ for eachThe management plan will differ for each
specific patientsspecific patients

22. Things Happened During RamadanThings Happened During Ramadan
• Eating habits change in many waysEating habits change in many ways
– Meal time changeMeal time change
– Pattern of mealPattern of meal
– Calorie intakeCalorie intake
• Increased in post prandial physical activity duringIncreased in post prandial physical activity during
the nighttimes associated with Tarawih.the nighttimes associated with Tarawih.
• Psychological changes due to the generalPsychological changes due to the general
spiritual atmosphere during Ramadan, whichspiritual atmosphere during Ramadan, which
create a feeling of inner well-beingcreate a feeling of inner well-being

23. General advice for those who fastGeneral advice for those who fast
• Consult your doctor first for pre RamadanConsult your doctor first for pre Ramadan
medical assessment & educationmedical assessment & education
• Practice fasting in Shaban firstPractice fasting in Shaban first
• With the approval of physician switch to eitherWith the approval of physician switch to either
long acting or twice daily medicationlong acting or twice daily medication
• Elderly patients on NSAID should have frequentElderly patients on NSAID should have frequent
monitoring of renal functionsmonitoring of renal functions
• Anticoagulant and Antiplatilate medicationsAnticoagulant and Antiplatilate medications
should be given at nightshould be given at night

24. Education & CounselingEducation & Counseling
Educate the patients regarding
– Acute complications & their management
– Blood sugar monitoring
– Meal planning
– Physical activity
– Drug adjustment

25. Benefits of Education & CounselingBenefits of Education & Counseling
according to the READ studyaccording to the READ study

26. READ

27. What about diet & exercise?What about diet & exercise?

28. Diet in RamadanDiet in Ramadan
 Total calorie should not be changed
 Divide food in to 2-3 meal: Iftar, Dinner & Suhur
 Limit the amount of sweet food taken at Iftar
 Limit the fried food
 Choose sugar free type drinks
 Drink plenty of water
 Use sugar free sweetener where needed
 Fill up on starchy food during dinner and Suhur-
rice, chapati, nan, vegetables, dal, fish, meat,
egg, milk, yoghurt and fruits

29. Exercise in RamadanExercise in Ramadan
 Physical activity should be reduced during
day time
 Exercise can be performed for an hour after
Iftar or after Tarawih prayer
 Increased prayer during Ramadan should be
taken into account

30. Adjustment of DrugsAdjustment of Drugs

31. Before Ramadan During Ramadan
Patients on “diet and
exercise”
- No change is needed
- Modify time & intensity of
exercise
- Ensure adequate fluid
intake
Treatment RecommendationsTreatment Recommendations

32. Before Ramadan During Ramadan
Sulfonylurea Once Daily:
Morning dose.
e.g., Gliclazide MR/60
Glimepiride
Iftar: Full Morning Dose
Sulfonylurea Twice Daily:
Morning & Evening dose.
e.g., Gliclazide
Glibenclamide
Iftar: Full Morning Dose
Suhur: ½ Evening Dose
Treatment RecommendationsTreatment Recommendations
Majority of our type 2 diabetic patients are treatedMajority of our type 2 diabetic patients are treated
with Sulfonylurea & Metforminwith Sulfonylurea & Metformin

33. Before Ramadan During Ramadan
Metformin 500 mg thrice
daily
Iftar: 1,000 mg,
Suhur: 500 mg
Treatment RecommendationsTreatment Recommendations

34. Before Ramadan During Ramadan
DPP4 inhibitor As usual at night
Glitazone As usual at night
Glinide As usual at night
Treatment RecommendationsTreatment Recommendations

35. Before Ramadan During Ramadan
Premixed insulin 30
Morning: (30 U)
Dinner: (20 U)
Iftar: Full Morning Dose (30 U)
Suhur: ½ Dinner Dose (10 U)
Basal Analogue At the same time
20-30% dose reduction
Split Mixed (R+N)
R+0+R
N+0+N
R+0+50%of R
N+0+50%of N
R+R+R
0+0+N
R+R+50% of R
0+0+50% of N
Treatment RecommendationsTreatment Recommendations

36. Can a patient monitorCan a patient monitor
blood sugar while fasting?blood sugar while fasting?

37. Monitoring RecommendationsMonitoring Recommendations
 Patients should monitor their blood glucose evenPatients should monitor their blood glucose even
during the fast to recognize subclinical hypo andduring the fast to recognize subclinical hypo and
hyperglycemiahyperglycemia
 Islam allows diabetics to have regular blood testIslam allows diabetics to have regular blood test
while fastingwhile fasting
 If blood glucose is noted to be low (<60mg/dl), theIf blood glucose is noted to be low (<60mg/dl), the
fast must be brokenfast must be broken
 If blood glucose is noted to be (>300mg/dl),If blood glucose is noted to be (>300mg/dl),
ketonesketones
in urine should be checked & medical advicein urine should be checked & medical advice
soughtsought

38. Ramadan AwarenessRamadan Awareness
Activities in BangladeshActivities in Bangladesh

39. Awareness: SymposiumAwareness: Symposium
DHAKA 2006DHAKA 2006 SYLHET 2007SYLHET 2007
KHULNA 2008KHULNA 2008 COMILLACOMILLA

40. Awareness: SymposiumAwareness: Symposium
BARISAL 2010BARISAL 2010 TONGI & GAZIPUR 2011TONGI & GAZIPUR 2011
KUSHTIA 2012KUSHTIA 2012JESSORE 2012JESSORE 2012

41. Awareness: SymposiumAwareness: Symposium
NARAYANGONJ 2013NARAYANGONJ 2013 SAVAR: Enam Medical 2013SAVAR: Enam Medical 2013
Hotel Ruposhi Bangla, DHAKAHotel Ruposhi Bangla, DHAKA

42. Awareness Poster: Expert opinion on BloodAwareness Poster: Expert opinion on Blood
sugar monitoring while fasting in Ramadansugar monitoring while fasting in Ramadan

43. Awareness: Physician’s GuidelineAwareness: Physician’s Guideline

44. Awareness: Print MediaAwareness: Print Media

45. Awareness: Press ConferenceAwareness: Press Conference
Inauguration of “Ramadan & Diabetes” bookInauguration of “Ramadan & Diabetes” book

46. Review ArticlesReview Articles

47. ConclusionConclusion
 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

48. Thank YouThank You