Practical Management of Type 2 DiabetesPractical Management of Type 2 DiabetesDuring the Holy Month of RamadanDuring the Holy Month of Ramadan

Prof. Md. Farid UddinChairman & Coordinator

Department of Endocrinology Bangabandhu Sheikh Mujib Medical University

Dhaka, BangladeshEmail: dr.md.fariduddin@gmail.com

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

Frequently asked questions during Frequently asked questions during RamadanRamadan

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?

Can a diabetic patient fastCan a diabetic patient fastduring Ramadan? during Ramadan?

IslamiCity.com- Ramadan Fasting and Diabetes IslamiCity.com- Ramadan Fasting and Diabetes Mellitus Mellitus

The bulk of literature indicates that The bulk of literature indicates that fasting in Ramadan is safe for the fasting in Ramadan is safe for the majority of diabetic patients, but…majority of diabetic patients, but…

Patient needs-Patient needs-

1.1. Pre-Ramadan assessmentPre-Ramadan assessment2.2. Proper educationProper education3.3. ManagementManagement

Physician’s Role?Physician’s Role?

Guidance and advice to allow Guidance and advice to allow diabetic patients to fast as safely diabetic patients to fast as safely

as possibleas possible

Pre-Ramadan AssessmentPre-Ramadan Assessment

1.1. Assessment of glycemic Assessment of glycemic statusstatus

2.2. Assessment of complications Assessment of complications & co-morbid conditions& co-morbid conditions

3.3. Assessment of patient’s Assessment of patient’s abilityability

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 followingare 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

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 followingare advised not to fastare advised not to fast

Benefits associated with Benefits associated with fastingfasting

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

General BenefitsGeneral Benefits

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.

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)”

What are the risksWhat are the risksassociated with fasting?associated with fasting?

Major risks associated with fastingMajor risks associated with fastingin patients with diabetesin patients with diabetes

Hypoglycemia

Hyperglycemia

Dehydration

Weight changes

DIABETES CARE, VOLUME 28, NUMBER 9 SEPTEMBER 2005

Special precautions are recommendedSpecial precautions are recommendedto 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

Management of hyperglycemiaManagement of hyperglycemiain type 2 diabetes while in type 2 diabetes while

fastingfasting

Individualization Individualization

• Care must be individualizedCare must be individualized• The management plan will differ for The management plan will differ for

each specific patientseach specific patients

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 Increased in post prandial physical activity during the nighttimes associated with Tarawih.during the nighttimes associated with Tarawih.

• Psychological changes due to the general Psychological changes due to the general spiritual atmosphere during Ramadan, which spiritual atmosphere during Ramadan, which create a feeling of inner well-beingcreate a feeling of inner well-being

General advice for those who fastGeneral advice for those who fast

• Consult your doctor first for pre Ramadan Consult 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 With the approval of physician switch to

either long acting or twice daily medicationeither long acting or twice daily medication• Elderly patients on NSAID should have Elderly patients on NSAID should have

frequent monitoring of renal functionsfrequent monitoring of renal functions• Anticoagulant and Antiplatilate medications Anticoagulant and Antiplatilate medications

should be given at night should be given at night

Education & Counseling Education & Counseling

Educate the patients regarding– Acute complications & their

management– Blood sugar monitoring– Meal planning– Physical activity– Drug adjustment

Benefits of Education & CounselingBenefits of Education & Counselingaccording to the READ study according to the READ study

READ

What about diet & exercise?What about diet & exercise?

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

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

Adjustment of DrugsAdjustment of Drugs

Before Ramadan During RamadanPatients on “diet and exercise”

- No change is needed - Modify time & intensity of exercise- Ensure adequate fluid intake

Treatment RecommendationsTreatment Recommendations

Before Ramadan During RamadanSulfonylurea Once Daily: Morning dose.e.g., Gliclazide MR Glimepiride

Iftar: Full Morning Dose

Sulfonylurea Twice Daily: Morning & Evening dose.e.g., Gliclazide Glibenclamide

Iftar: Full Morning DoseSuhur: ½ Evening Dose

Treatment RecommendationsTreatment Recommendations

Majority of our type 2 diabetic patients are treatedMajority of our type 2 diabetic patients are treatedwith Sulfonylurea & Metforminwith Sulfonylurea & Metformin

Before Ramadan During RamadanMetformin 500 mg thrice daily

Iftar: 1,000 mg,Suhur: 500 mg

Treatment RecommendationsTreatment Recommendations

Before Ramadan During RamadanDPP4 inhibitor As usual at night

Glitazone As usual at night

Glinide As usual at night

Treatment RecommendationsTreatment Recommendations

Before Ramadan During RamadanPremixed 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+RN+0+N

R+0+50%of RN+0+50%of N

R+R+R0+0+N

R+R+50% of R0+0+50% of N

Treatment RecommendationsTreatment Recommendations

Can a patient monitor Can a patient monitor blood sugar while fasting?blood sugar while fasting?

Monitoring Recommendations Monitoring Recommendations

Patients should monitor their blood glucose Patients should monitor their blood glucose eveneven during the fast to recognize subclinical hypo during the fast to recognize subclinical hypo andand hyperglycemia hyperglycemia

Islam allows diabetics to have regular blood Islam allows diabetics to have regular blood testtest while fasting while fasting

If blood glucose is noted to be low (<60mg/dl), If blood glucose is noted to be low (<60mg/dl), thethe fast must be broken fast 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 advice in urine should be checked & medical advice soughtsought

Ramadan AwarenessRamadan AwarenessActivities in BangladeshActivities in Bangladesh

Awareness: SymposiumAwareness: Symposium

DHAKA 2006DHAKA 2006 SYLHET SYLHET 20072007

KHULNA KHULNA 20082008

COMILLA 2009COMILLA 2009

Awareness: SymposiumAwareness: Symposium

BARISAL BARISAL 20102010

TONGI & GAZIPUR 2011TONGI & GAZIPUR 2011

Kushtia 2012Kushtia 2012Jessore Jessore 20122012

Awareness: SymposiumAwareness: Symposium

Narayangonj Narayangonj 20132013

Savar: Enam Medical Savar: Enam Medical 20132013

Hotel Ruposhi Bangla, Dhaka 2013Hotel Ruposhi Bangla, Dhaka 2013

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

Awareness: Physician’s GuidelineAwareness: Physician’s Guideline

Awareness: Print MediaAwareness: Print Media

Awareness: Press ConferenceAwareness: Press Conference

Inauguration of “Ramadan & Diabetes” Inauguration of “Ramadan & Diabetes” bookbook

Review ArticlesReview Articles

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

Thank YouThank You