Patients with diabetes who have moderate risk of adverse events can fast with caution-Dr. Samad Shera


 International Conference on Fasting and Ramadan

Patients with diabetes who have moderate
risk of adverse events can fast with
caution - Dr. Samad Shera

Early discontinuation of fasting is recommended in case
of symptoms of hypoglycaemia or hyperglycemia - Prof. Basit

KARACHI: Jinnah Sindh Medical University in collaboration with Baqai Institute of Diabetes and Endocrinology (BIDE) organized a two day international conference on Diabetes and Ramadan which attracted a large number of Diabetologists and endocrinologists from all over the country besides a few delegates from Iran, Malaysia and UAE.

Dr. A. Samad Shera from Diabetic Association of Pakistan was the first speaker in the first scientific session chaired by Prof. Fereidoun Azizi from Iran. He pointed out that patients who are old, poorly controlled diabetics, patients with diabetes who have complications, pregnant women on insulin or OHA are exempt from fasting. Pre Ramadan assessment of all those patients who are diabetic is necessary. These patients must have facilities for monitoring their blood glucose before Sehar and Iftar particularly those who are on insulin therapy. These patients must break their fast if there are symptoms of hypoglycaemia. If their blood sugar is 60mg/dl or less than 70 after few hours of starting the fast. They are required to take healthy balanced diet. Simple carbohydrates are more appropriate. They should be advised to increase their liquid intake. For them best time for walk is before Sehari meal and they should not do any exercise before Iftar. Those patients who have moderate risk of adverse events can fast with caution.


Prof. Zaman Sheikh presenting a memento to Sindh Health Minister
Mr. Jam Mehtab during the inaugural session of International
Conference on Diabetes and Ramadan. On extreme left is
Prof. Tariq Rafi Vice Chancellor of Jinnah Sindh Medical University.

Fasting is not recommended for those patients who have severe hyperglycemia, DKA recent hypoglycaemia, Type 1 diabetes mellitus, acute illness, those who are on dialysis, and those who have to do intense physical labour. Dose of insulin has to be adjusted during Ramadan. Patients whose blood glucose is controlled can fast. These patients should be prepared to break fast if hypoglycaemia occurs. They should be given short acting insulin’s. DKA, dehydration, hypoglycaemia, hyperglycemia are some of the problems which patients might face during fasting. Insulin can be taken during fasting and blood tests can also be done during fasting.

Dr. Tahir Yousufzai from Aga Khan University was the next speaker who made a presentation on behalf of Abdulbarj  Bener from Turkey. His topic was effects of Ramadan Fasting on Diabetes Mellitus- a global health problem. He pointed out that obesity is very high in Gulf countries. According to some studies 58% men and 65% women are obese. A study conducted in Qatar during 2007-2008 which enrolled 1434 people from  ten primary healthcare centers showed that overall prevalence of diabetes was 16.7%, 15%  in male and 18% in female were diabetic. Second study included Qatri and Non Qatri population which was conducted in 2012 and 2013. Qatari are not physically active. The study showed that blood pressure and blood glucose both reduced during Ramadan. This study also showed that 6% of patents were not aware of their disease, fasting reduced their HbAIc. The study concluded that patients with diabetes can fast after consulting their doctor. Prof. Aziz in his remarks said that we need local studies and our own figures. Diabetes is variable in different communities. Our guidelines and statements should not be based on advice from experts from overseas.

Dr. Mafauzy Mohammad from Malaysia gave details of 2015 practical guidelines for diabetes mellitus. He discussed in detail the benefits and risks during fasting and how to monitor those who are at risk during fasting. Benefits of fasting include decrease in weight, increase in HDL, improvements in glucose control, and decrease in Systolic Blood Pressure during day time, reduction in Cardiovascualr diseases markers. The risks, he mentioned, included hypoglycaemia, hyperglycemia, DKA, dehydration. Patient education, he said, was extremely important. They should be educated what to do in case they have symptoms of hypoglycaemia, hyperglycemia or dehydration.  Patients on insulin are required to test their blood glucose five times a day. They should never skip Sehri, have balanced meal, limit the use of fry, fatty food, take good fluids and replenish liquid taking about eight glasses per day and make sure to consume sugar free drinks.

Prof. Jamal Zafar, Prof. Mohsen Nematy, Prof. Bilal Bin Younis, Prof. Saify and others being presented 
mementoes during the international conference on Diabetes and Ramadan. Photographed on 
extreme right are Dr. Sobia Sabir, Dr. Bilal Bin Younis and Dr. Osama.

Prof. Mohsin Nematy from Iran along with Prof. Jamal Zafar and Prof. Jamil Ahmad chaired the next session. Prof. Abdul Basit from BIDE was the first speaker who talked about Diabetes and Ramadan- some recent endeavours in Pakistan. He first referred to the EPIDAR study which was conducted in thirteen countries which showed that 43% patients with T1DM and 73% with T2DM fast. This study had many limitations as it was a retrospective study. Diabetics should be healthy and it is obligatory to ensure safety concerns before fasting. Some patients do fast though they are on dialysis. He emphasized the importance of pre-Ramadan counseling of these patients. A Ramadan Study Group was constituted at BIDE in 2008. It is busy in education and research.  It consists of doctors, diabetes educators. We started educating the community. D.Net has links with eight centers involved in diabetes education. We are developing diabetes education. Early discontinuation of fasting is recommended in case of symptoms of hypoglycaemia or hyperglycemia. These patients can break fast without Kafara. Insulin dose has to be adjusted in Type 2 DM patients who are fasting. We should endeavor to ensure safe fasting at the community level. We should cover religious aspects and ensure implementation of the Guidelines, he remarked.

Prof. Zaman Sheikh discussed Impact on Health with nutritional variations. He pointed out that different studies have showed different results as regards Ramadan and Diabetes. During Ramadan we consume lot of fatty food and special foods are prepared. Studies have shown that renal functions are not altered in healthy subjects during fasting.  Patients are advised to take atleast eight glass of liquids between Sehar and Iftar, stay in cool area and reduce physical activity. We need to promote healthy eating during Ramadan. Fasting does not lead to malnutrition however intake of unbalanced diet during fasting can make acute and chronic diseases worse. Balanced diet can manage negative effects of fasting. Dr. Qamar Masood in his presentation laid emphasis on dose adjustment of insulin therapy. Breaking fast due to medical reasons, he opined, is not bad. People with medical conditions are not allowed to fast because of adverse effects. The desirable blood glucose levels are between 80-120 before Sehar, between 140-200 two hours after Sehar and  100-140 during mid day.

Prof. A.H. Amir from Peshawar speaking on management of diabetes during Ramadan said that weather conditions are different in different countries and it has its effects on fasting. Continuous glucose monitoring is difficult. There is no data available as these are challenging patients. CGM is an advocacy tool for our patients. We need to plan a study and use modern tools in it. He also disclosed that they are forming KPK Diabetes Forum and its meeting is planned on November 13-14th this year.


Group photograph of some of the guests along withorganizers of the International Conference
on Diabetes
and Ramadan after the inaugural session held at a local hotel.

Prof. Yakoob Ahmedani from BIDE gave details of a mini survey conducted in 2014 in seven countries including Pakistan. Other countries involved were Bangladesh, Afghanistan, Saudi Arabia, Oman, and Egypt. Total patients included were 6610. Some of these patients with diabetes fast for ten days, some fast for twenty two days. Some of these patients were fasting for the last thirty five years. This study showed that there was  10% increase in physical activity during Ramadan, 17% increase in food intake and some had  29% decrease in food intake. Sugar intake was increased by 11.7%. Over 52.5% of patients did not receive any education before Ramadan. Physicians change their drugs in most of the cases and 30% did not receive any dietary information. Comparing the two group’s one which had education before Ramadan and the other which had no education showed that symptoms of hypoglycaemia were similar in both groups. Education group had more monitoring, drugs dosage was changed more frequently; frequency of hypoglycaemia was similar in both the groups. For breaking fast education is important in diabetic care. There were similar results in hyperglycemia. Self Monitoring of Blood Glucose improved significantly in 2014. The incidence of hypoglycaemia reduced significantly as compared to 2004.His conclusions was that diabetes specific education is the cornerstone in safe fasting. 

Prof. Bilal Bin Younis along with Dr. Sobia Sabir chaired the afternoon session. Prof. Zafar Saeed Saify spoke on maintaining of drug administration during Ramadan. Administration routes, he said, do not nullify fasting. One can use nasal drops, nasal spray as well as inhalers. Anal injections can be given if patient decides to fast during surgery. Efficacy and toxicity of drugs vary based on time of administration. In case of acidity, Aspirin and NSAIDs should not be taken, he added.

Dr. Abbas Raza from SKMT talked about management of special medical conditions. He pointed out that special situations require special interventions. Ramadan involves the whole family. One has to be careful with steroid use, thyroid disorders, choice of a drug while managing primary and secondarily adrenal insufficiency. Steroids have effects on blood glucose. Speaking about thyroid disorders, he said that thyroid levels do fluctuates in Ramadan. One can take the drug half an hour before Sehar or Thyroxin can be taken at bed time since many patients cannot  get up one or two hours before Sehar. Adolescents have problems with the use of insulin. He also discussed management of diabetes and infections during Umra and Ramadan, foot care in Ramadan, management of diarrhoea and dehydration. Diabetics should be educated when to break their fast, he added.

Dr. Musarrat Riaz from BIDE spoke about role of education in management of diabetes mellitus. She pointed out that now lot of data is published and some is in review stages. Educating the patients is vital for management of diabetes mellitus. In one of our study almost 30% of patient had no idea whether they can check their blood glucose in Ramadan. Those patients who had some education before Ramadan had less severe complications. She further stated that individualized education and diabetes treatment plan help the patient. It is important that patients as well as healthcare professionals both are educated in addition to dietary counseling. Prof. Rubina Hakeem also addressed the audience.

Prof. Yakoob Ahmedani along with Dr. Saeed Mahar chaired the first session on the second day of the conference. Prof. Mohsin Namety from Iran was the first speaker who said some studies have showed that during Ramadan there is weight reduction. Some studies have showed that there is no significant change in blood pressure and heart failure. In one of the studies there was a significant increase in HDL after fasting. Significant improvement in ten yeas CAD and Heart Failure risk was noted in another study. Fasting is good for young girls. Ramadan, he said does not need change of dose of levothyroxine in hypothyroid patient. One can take this medication at bed time or two hours before Sehari. He also talked about fasting and vision skills, dehydration theory and suggested that we need Journals on Fasting and regular conferences on Ramadan and Health like the one we are having today. We need to write books on fasting, chapters on fasting in the text books. We have recently started a Journal of Fasting and Health in Iran. We have written a book on Fasting in Health and Disease. It is being translated in Persian and Urdu besides Malavi. Fasting, he said, needs more research in health and disease, it is safe and healthy and it should be encouraged.

Prof. Abdul Jabbar from UAE speaking on Diabetes and Ramadan gave details of EPIDIAR vs CREED study. He pointed out that 60% of Muslim population lives in Asia and 300 Million Muslims live in non-Muslim countries. Gestational Diabetes is there. Diabetes and pregnancy are problems in non-Muslim countries as well. These are our problems and we have to work on it ourselves to find a solution. About 10% of women in Muslim countries may be pregnant in Ramadan. About 1% or less will be in Non-Muslim countries. India has the third largest Muslim population in the world. EPIDIAR enrolled thirteen hundred patients from thirteen countries. It used to be said that Type1 DM should not fast but there were 51% who did fast. We need more publications before fasting. Risk of patients during fasting is now known. We need to know how to avoid hypoglycaemia, hyperglycemia and DKA.

CREED was a retrospective study which included Type 1 and Type 2 as well as Gestational Diabetes of eighteen years old or above. Type1 had 144 patients, Type 2 had 3260 patients. About 48.3% had HbAIc less than 7.5. About 25% of patients started having physical activity. The incidence of neuropathy reduced but nephropathy remained the same. Diabetic foot ulcer was 3.9% as compared to 5.1% in EPIDIAR study. CREED study results showed that in Type 1 DM had 14.6% low risk while in Type 2 DM had 33.3% low risk. More people were fasting in CREED as compared to EPIDIAR. About 29.9% diabetic suffering from Type 2 diabetes mellitus fast outside Ramadan. In fact all complications went down in the CREED study, he added.

Dr. Mohammad Saiful Haque from BIDE made a presentation on safety in fasting in Type 1 DM patients. It was a prospective study. EPIDIAR showed that 43% T1DM were fasting. They included fasting and non fasting patients from the OPD. Those patients with serious complications were excluded. A twenty four hour help line was provided to them to advise them when to break fast. HbAIc was measured one month before and one month after Ramadan. The study included twenty male and twenty two female and their mean duration of diabetes was 7.1 years. Fasting group had 61% episodes of hypoglycaemia. It was the effect of education that 23% discontinued fast when they had symptoms of hypoglycaemia. 76% checked their blood glucose when they had hyperglycemia symptoms and 5.8% discontinued fast because of hyperglycemia. Hyperglycemia is seen at bed time or two hours after Iftar. HbAIc in these patients did decline but it was not significant. Conclusions from their study were that majority of the patients with Type1 diabetes did not have any serious complications. Six patients had to break fast. None of the patients developed DKA and none needed hospitalization. It shows the benefits of diabetic education and supervision, he remarked.

Dr. Shabeen Naz Masood’s presentation was “Is it safe to fast during pregnancy”? She pointed out that gestational age and physical fitness matters.  We need to find out Islamic and medical view if the patients break fast a few minutes before Iftar. One of the studies has shown that mothers may have small babies with learning disabilities but this study had many deficiencies. A study from Iran showed that there was no significant difference in pregnancy outcome as regards weight, height and head circumference of infant. There were no significant adverse effects of fasting on maternal health.  She concluded her presentation by stating that pregnant women who wish to fast should plan ahead, pay attention to mild problems, worrying signs should be looked for. Those pregnant women who notice increase or decrease in fetal movement should not be fasting.

Prof. Jamil Ahmad from Baqai Medical University chaired the next session which was moderated by Dr. Osama from Islamabad. Prof. Asim Ahmad from Kidney Center talked about to fast or not to fast – concern for renal patients. He pointed out that drinking part was the major problem in patents’ suffering from renal diseases during fasting. Patients with stone disease, single kidney, donor and recipient, those with acute kidney injury, chronic kidney disease or those who are on dialysis should not fast. Patients should not let the urine concentrate. Those with stone colic episode or stone formation most often have no problems. In case of patients with single kidney, in case of donors there is no issue to fast if their kidney function is good. So is the case for recipient if they have stable renal function. Those with acute kidney injury should not fast because of abrupt or rapid decline in renal filtration function.

Common causes of chronic kidney disease include hypertension, use of NSAIDs etc. More than 20% of persons aged forty years or more have reduced kidney function. Those with early kidney disease have to be careful. Most chronic kidney disease patients who are stable will be able to fast. At the Kidney Center we have thirty dialysis stations and now this number is being increased to sixty five by adding two more floors on the building. We have 370 chronic kidney disease patients on maintenance therapy at present. Those patients who are on hemodialysis and are fit can fast but during fasting they should not be dialyzed. Referring to a study with 1841 patients, he said, most patients who were on dialysis died during Ramadan. Large numbers of patients who are dialyzed do not fast but still death was high in Ramadan among those who were on dialysis. During 2015, they had three, six and three deaths before, during and after Ramadan respectively among patients who were on dialysis. Forty four patients are on dialysis for more than ten years. He was of the view that perhaps it is not fasting but feasting which is the problem.

Prof. Wassay from Aga Khan University spoke about fasting and brain health. He said that brain diseases are the No.1 cause of disability and it accounts for more than 20% of disease burden. It includes stroke, depression, and dementia.  People with dementia are fast growing in the world. Elderly population is increasing hence we have more people with neurological diseases. Life expectancy in Pakistan is 63 years in male and 67 years in female and fasting has effects on aging. At present lot of research is being conducted on fasting. It has been shown that if you cut down your food intake, it increases your life. During fasting mood is elevated, there is decrease in depression and suicidal thoughts. During fasting the people have increased ability to handle stress; it decreases anxiety, panic attacks. Mood stabilization has been noticed in bipolar disorders. Fasting added with anti psychotics has better effects on those suffering from schizophrenia. There is decrease in carving for addiction while fasting. Fasting also delays the onset of Alzheimer’s disease and other types of dementia. Fasting improves tremor and stroke incidence is reduced during fasting which may be due to blood pressure, cholesterol, blood glucose control. Fasting improves epilepsy control, improves fits and also improves effects of drugs and medications. It improves stage 3 and 4 sleep. Sixteen to eighteen hours fasting improves quantity and quality of sleep and there is decrease in night terrors. Future research should focus on effects of fasting on community health, effects of fasting on long term persistent fasting and sustained effects on short term fasting besides neurological effects on intermittent fasting. Fasting does improve brain function, brain health and it also improves disease control, he remarked.

Participating in the discussion Prof. Basit said that mortality is high in UK during December and January because there is less number of doctors, health service providers during this period.  Is it that the patients are not brought to the hospitals which has something to do with it, he asked.

Prof. Nazli Hussain from DUHS spoke on Does Ramadan effect fetal growth? She pointed out that there are many studies from Iran and Saudi Arabia which have shown that fetal growth is not affected during Ramadan. One of the studies showed that placental size was small of babies during fasting when these babies were in utero during Ramadan. They included hundred consecutive women before the start of Ramadan, fifty were in Group A and fifty were in Group B. Gestational age was less than twenty week and they were all Singleton pregnancy.  Fetal biometry and Doppler studies were done. Sixty seven women completed the study of which 37 were fasting and twenty eight did not fast.  They found no significant difference in the outcome in both the groups. Their conclusions were that they did not notice any delay in fetal growth during Ramadan. Muslim world, she said, needs to do more studies on this topic as it is our problem.

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