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This section of the website is for UK healthcare professionals only. If you are not a healthcare professional, please click here.

Module 1: The Impact of Fasting (15 mins)

This module covers the cultural significance of fasting during Ramadan, the physiology of fasting for older people with T2DM and tips on how you can provide advice and education to your patients.

Pass mark: 100%

Number of questions: 3

Ramadan: One of the Five Pillars of Islam

  • The Islamic month of Ramadan is one of the longest periods of religious fasting. During this time, Muslims abstain from eating, drinking and taking medication from before sunrise to sunset
  • More than 50 million people with diabetes fast during Ramadan1
  • According to guidelines from both religious and medical organisations, most people living with diabetes are excused from fasting because of the increased associated health risks, including hypoglycaemia, hyperglycaemia, dehydration and thrombosis1
  • Still, choosing to fast is a personal decision and many people with diabetes do not adhere to these guidelines

Reference

  1. Al Arouj et al., Diabetes Care, 2010; 33(8): 1895–1902.

What Does Ramadan Fast Mean?

  • Ramadan or the Arabic translation, “sawm”, means “abstention from”
  • Fasting is from the period of dawn (sahur) to sunset (iftar) and so most individuals observing Ramadan will have two meals in a 24-hour period. In the UK, each fast can last between 10 and 20 hours. During the period of fasting an individual must refrain from smoking, eating, drinking, sexual activity, consuming oral medications and using intravenous fluids
  • The fasting period lasts for 29–30 days

Significance of Ramadan Amongst Older People

  • Many older Muslims may have been fasting annually since around 10 years of age; religious identity amongst older members of the community is especially strong, often manifesting in an unwavering need to fast1
  • Aside from following religious teachings of the Quran, older Muslims report increased self-esteem and self-satisfaction1
  • Deciding not to fast may be considered shameful. Furthermore, those who do not fast may be considered “non-believers” and some would prefer risking metabolic complications than being labelled as such1
  • The older people and chronically ill are exempt from fasting. However:
    • The EPIDIAR study showed that 42.8% of patients with type 1 diabetes and 78.7% with type 2 diabetes fasted for 15 days or more2
    • The CREED study reported that 94.2% of those with type 2 diabetes fasted for at least 15 days, and 63.6% fasted every day3

References

  1. Azzoug S et al., J Park Med Assoc, 2015; 65 (Suppl 1): S33–36.
  2. Salti I et al., Diabetes Care, 2004; 27(10): 2306–2311.
  3. Babineaux S, et al., Diabet Med, 2015; 32: 819–828.

Exemptions to Ramadan

Not all Muslims are expected to fast if considered detrimental to health; individuals can be either permanently or temporarily exempt1,2

  • Those who are temporarily exempt may make up their fasts at a later date
  • Those who are permanently exempt must pay compensation in the form of giving alms to the poor
View Temporary and Permanent Exemptions

Permanent Exemptions:

  • Children under the age of puberty
  • The old and frail
  • Those with learning difficulties
  • Those with severe mental health illness
  • Those with a chronic condition (e.g. type 2 diabetes with unstable disease; diabetes with complications)

Temporary Exemptions:

  • Pregnant women
  • Breastfeeding women
  • Travellers (where journeys are >50 miles)
  • Those who are acutely unwell

References

  1. Gilani A., Diabesity in Practice 2012; 1(2): 63–68.
  2. Karamat et al., J R Soc Med, 2010; 103: 139–147.

Ramadan Dates 2019

There are several important dates you should be aware of, as a healthcare professional:

*Eid al-Fitr marks the end of Ramadan

Note: These dates may vary

Feeding in Healthy Individuals

Feeding in Healthy Individuals image

Adapted from Diabetes and Ramadan: Practical Guidelines. International Diabetes Federation (IDF), in collaboration with the Diabetes and Ramadan (DAR) International Alliance (2016)1

  • In healthy individuals, increased glucose levels in the blood after eating stimulates insulin secretion from the islet cells of the pancreas
  • This insulin triggers the liver and muscles to store glucose as glycogen

Reference

  1. International Diabetes Federation (IDF), in collaboration with the Diabetes and Ramadan (DAR) International Alliance (2016) Diabetes and Ramadan: Practical Guidelines.

Fasting in Healthy Individuals

Fasting in Healthy Individuals image

Adapted from Diabetes and Ramadan: Practical Guidelines. International Diabetes Federation (IDF), in collaboration with the Diabetes and Ramadan (DAR) International Alliance (2016)1

  • During fasting, circulating glucose levels fall and insulin secretion is suppressed
  • Glucagon and catecholamine secretion is increased, stimulating glucogenolysis and gluconeogenesis
  • Liver glycogen is converted to glucose – enough for the brain and peripheral tissues for around 12 hours
  • When glycogen stores are depleted and insulin levels are low, fatty acids are oxidised to ketones (ketogenesis), which can be used as fuel by many organs, preserving glucose for the brain
  • Those with a chronic condition (e.g. type 2 diabetes with unstable disease; diabetes with complications)

Reference

  1. International Diabetes Federation (IDF), in collaboration with the Diabetes and Ramadan (DAR) International Alliance (2016) Diabetes and Ramadan: Practical Guidelines.

Fasting in Diabetes

Fasting in Diabetes

Adapted from Diabetes and Ramadan: Practical Guidelines. International Diabetes Federation (IDF), in collaboration with the Diabetes and Ramadan (DAR) International Alliance (2016)1

  • During fasting in diabetes, glucose homeostasis is disturbed by both the underlying pathophysiology and medications
  • When fasting, insulin resistance/deficiency can lead to excessive glycogen breakdown and increased gluconeogenesis and ketogenesis in patients with diabetes
  • The risks facing people with diabetes are heightened during Ramadan, including hypoglycaemia, hyperglycaemia, diabetic ketoacidosis, dehydration and thrombosis
  • Feasting during Ramadan also carries risks for those with diabetes

Reference

  1. International Diabetes Federation (IDF), in collaboration with the Diabetes and Ramadan (DAR) International Alliance (2016) Diabetes and Ramadan: Practical Guidelines.

Impact of Fasting in Diabetes

Impact of Fasting in Diabetes image

When fasting, insulin resistance/deficiency can cause excessive breakdown of glycogen and increased gluconeogenesis in people with diabetes;1 on the following slides you will learn about their impact on older people.

Reference

  1. Hassanein M et al., Diabets Res Clin Pract, 2017; 126: 303–316.

Hypoglycaemia and Hyperglycaemia

Hypoglycaemia

  • Older people with diabetes, especially the frail, are at increased risk of hypoglycaemia1
  • Precipitating factors are long fasting hours, missing Sahur (dawn) meal and failure to modify drug dosage and timing2
  • In the EPIDIAR study:3
    • Fasting during Ramadan increased the risk of severe hypoglycaemia by 4.7 fold in patients with type 1 diabetes and 7.5 fold in patients with type 2 diabetes

Hyperglycaemia

  • Precipitating factors are lack of diet control during Iftar meal and excessive reduction of drug dosages due to fear of hypoglycaemia2
  • In the EPIDIAR study:3
    • Fasting during Ramadan increased the risk of severe hyperglycaemia by 3.2 fold in patients with type 1 diabetes and 5 fold in patients with type 2 diabetes
  • Pay attention to older people who prefer soft and sweet foods:1
    • Symptoms of hyperglycaemia (fatigue, polyuria, urinary incontinence and cognitive impairment) may be wrongly attributed to ageing

References

  1. Azzoug S et al., J Park Med Assoc, 2015; 65 (Suppl 1): S33–36.
  2. Raveendran and Zargar, Cleveland Clin J Med, 2017; 84(5): 352–356.
  3. Salti I et al., Diabetes Care, 2004; 27(10): 2306–2311.

Diabetic Ketoacidosis

  • Precipitated by lack of diet control during Iftar (sunset) meal1
  • Because of absence or deficiency of insulin, the body cannot use glucose for energy and thus uses fats as an alternative2
  • Consequently, ketone bodies accumulate as a waste product and lead to diabetic ketoacidosis3
  • This occurs in almost 3.3% of those with type 1 diabetes3,4 causes nausea, vomiting, and abdominal pain and can progress to cerebral oedema, coma, and death5

References

  1. Azzoug S et al., J Park Med Assoc, 2015; 65 (Suppl 1): S33–36.
  2. Abdelgadir E et al., J D Metabol Dis, 2016; 15: 50.
  3. Temizhan A. and Dönderici O., Int J Cardiol, 1999; 70: 149–53.
  4. Health and Social Care Information Centre (2013) National Diabetes Inpatient Audit 2012, Leeds: HSCIC.
  5. Brutsaert E. Merck Manual: Diabetic Ketoacidosis. Last reviewed, February 2017. Available at: https://www.msdmanuals.com/en-gb/professional/endocrine-and-metabolic-disorders/diabetes-mellitus-and-disorders-of-carbohydrate-metabolism/diabetic-ketoacidosis-dka.

Diabetic Ketoacidosis

Diabetic ketoacidosis (DKA) is a medical emergency, associated with significant mortality1

  • DKA is an extreme consequence of insulin deficiency and can result in severe dehydration and electrolyte imbalance
  • Symptoms develop rapidly, over a few hours or days
  • If you suspect DKA, perform a finger prick glucose test and check urine for ketones
  • A glucose ≥11.1 mmol/L, with ketonuria ≥ ++ (or blood ketone >3 mmol/L) is highly suggestive of DKA
  • Arrange transfer to hospital immediately, by blue light ambulance if necessary to avoid delay

Reference

  1. Gibb FW et al., Diabetologia, 2016; 59: 2082–2087.

Diabetic Ketoacidosis: Symptoms

Symptoms develop rapidly and may include:

  • Polyuria
  • Polydipsia
  • Weight loss
  • Nausea, vomiting, abdominal pain
  • Weakness and lethargy
  • Acetone on breath (smell of pear drops)
  • Altered mental state
  • Kussmaul respiration (a characteristic deep hyperventilation)
  • Severe dehydration with loss of skin turgor, tachycardia, hypotension
Not everyone can smell ketones – do not rule out DKA if there is no smell image

DKA=diabetic ketoacidosis

Dehydration and Thrombosis

Two key concerns for patients with diabetes are dehydration and thrombosis

Dehydration

Dehydration may be compounded in hot climates or in individuals who undertake intensive physical labour, as well as by osmotic diuresis caused by hyperglycaemia.1

Dehydration can lead to hypotension and subsequent falls or other injuries.1,2

Thrombosis

Diabetes is a procoagulant condition and dehydration increases risk of thrombosis

References

  1. Raveendran and Zargar, Cleveland Clin J Med, 2017; 84(5): 352–356.
  2. Azzoug S et al., J Park Med Assoc, 2015; 65 (Suppl 1): S33–36.

Offering Advice

Studies have demonstrated a clear benefit of Ramadan-focused education programmes in terms of glycaemic control, weight loss and a reduced risk of hypoglycaemic events. According to joint guidelines issued by the International Diabetes Federation (IDF) and Diabetes and Ramadan (DAR) International Alliance, a structured educational programme should include advice on:1

  • Risk quantification
  • Blood glucose monitoring
  • Diet and exercise
  • Medication adjustments
  • Recognising symptoms of complications

The full UK guidelines on managing diabetes in Ramadan2 can be accessed by following this external link.

References

  1. International Diabetes Federation (IDF), in collaboration with the Diabetes and Ramadan (DAR) International Alliance (2016) Diabetes and Ramadan: Practical Guidelines.
  2. Ali S et al., Diabet Med, 2016; 33(10): 1315–1329.

General Guidance

When providing advice and education to older people, be mindful that:

  • Being an older individual does not automatically mean they are at high risk of complications
  • Evaluate individual risk by assessing the following parameters:1
    • Functional capacity
    • Cognition
    • Mental health
    • Comorbidity burden

However, for individuals who do fast…

  • Those with uncontrolled blood-sugar levels should be discouraged from fasting due to risk of hypoglycaemia
  • Should measure blood-sugar throughout the day and advised to break the fast if blood glucose <3.3 mmol/L (60 mg/dL) or if blood glucose >16.7 mmol/L (300 mg/dL)2 – and discuss any concerns that may arise about whether testing constitutes a breaking of the fast
  • Drink plenty of water at regular intervals after breaking the fast, to avoid dehydration2
  • The breakfast meal should be balanced in content, low-calorie, easily digestible and low fat ingredients3

References

  1. Azzoug S et al., J Park Med Assoc, 2015; 65 (Suppl 1): S33–36.
  2. Raveendran and Zargar, Cleveland Clin J Med, 2017; 84(5): 352–356.
  3. International Diabetes Federation (IDF), in collaboration with the Diabetes and Ramadan (DAR) International Alliance (2016) Diabetes and Ramadan: Practical Guidelines.

Individualised Patient Care

As in any population, you should keep in mind the principles of individualised care as set out by NICE1

  • Adopt an individualised approach to diabetes care that is tailored to the needs and circumstances of adults with type 2 diabetes, taking into account their personal preferences, comorbidities, risks from polypharmacy, and their ability to benefit from long-term interventions because of reduced life expectancy
  • Such an approach is especially important in the context of multimorbidity. Reassess the person's needs and circumstances at each review and think about whether to stop any medicines that are not effective
  • Take into account any disabilities, including visual impairment, when planning and delivering care for adults with type 2 diabetes

For more information on individualised care, download a copy of the NICE guidelines1 by clicking on the download button.

Download

Reference

  1. National Institute for Health and Care Excellence (NICE) (2015) Type 2 diabetes in adults: management (NG28). Updated May 2017.

Question 1

Amongst older Muslims, studies show that many individuals with diabetes choose to fast in spite of increasing their risk of diabetes-related complications: which of the following are possible reasons for this behaviour? (multi-select)

All of the above are possible reasons for somebody choosing to fast in spite of an increased risk.

All of the above are possible reasons for somebody choosing to fast in spite of an increased risk.






Question 2

Which set of features best describe the physiological changes that take place during a period of fasting in the diabetic state? (choose one)

Fasting decreased insulin secretion, leading to increased gluconeogenesis; in the diabetic state, fasting may increase gluconeogenesis to enhance glucose mobilisation as fuel for the peripheral tissues and the brain; eventually, ketogenesis may ensue as the glucose supplies deplete. Ketogenesis uses lipids as an alternative source of energy to glucose and may be dangerous in the diabetic state.

Fasting decreased insulin secretion, leading to increased gluconeogenesis; in the diabetic state, fasting may increase gluconeogenesis to enhance glucose mobilisation as fuel for the peripheral tissues and the brain; eventually, ketogenesis may ensue as the glucose supplies deplete. Ketogenesis uses lipids as an alternative source of energy to glucose and may be dangerous in the diabetic state.



Question 3

In older individuals deemed to be at risk of developing complications whilst fasting during Ramadan, what advice will you give them to avoid hypo- or hyper- glycaemia? (multi-select)

For individuals at increased risk of developing complications, you should advise them to monitor their blood glucose regularly throughout the day and to break their fast if their blood glucose levels go above 16.7 mmol/L (300 mg/dL) or fall below 3.3 mmol/L (60 mg/dL).

For individuals at increased risk of developing complications, you should advise them to monitor their blood glucose regularly throughout the day and to break their fast if their blood glucose levels go above 16.7 mmol/L (300 mg/dL) or fall below 3.3 mmol/L (60 mg/dL).





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Supporting documentation

GB-DIA-00251 | Date of Preparation: March 2019