Diabetes IN

RAMADAN

By:
Taif Aloufi
Khalid Alzibali
Osama Alnizari
 CASE SCENARIO

38 years old male patient diagnosed with Type 2 DM since 9

months present today at the clinic with HbAa1c 7.5 on
metformin500 MG and empagliflozin.
 PRE-RAMADAN ASSESSMENT

AIM:
WHEN:

Around 6–8 weeks before the start of

75 Ramadan. 1. Detailed medical history
% 2. Aspects of diabetes and ability to self-
manage
3. Presence of comorbidities
4. The individual’s prior experience in
managing diabetes during Ramadan fasting
5. The individual’s ability to self-manage
WHY: diabetes
6. Other aspects increasing the risk of fasting
To ensure that the diabetic patient was educated about his
fasting during the holy month of Ramadan, and to clarify the
risks he may be exposed to and how to avoid them as much
as possible.
 PRE-RAMADANASSESSMENT
PRE-RAMADAN ASSESSMENT

Ramadan-focused education Ramadan Nutrition Plan (RNP)

&
Key areas of education
 Ramadan-focused education

Objective

To raise awareness of the risks associated

75 with diabetes and fasting and to provide
% strategies to minimise them.

How

* simple
* Engaging
* Delivered in a culturally sensitive
manner by well-informed individuals
Risk quantification Exercise

Self-monitoring of Blood
Medication adjustments
Glucose (SMBG) during fasting

Fluids and dietary When to break the

advice fast
 Self-monitoring of Blood Glucose
(SMBG)

When to test?
There is a misconception held by some Muslim communities that pricking the
skin for blood glucose testing invalidates the Ramadan fast. actually checking
blood glucose levels is an essential component of diabetes care.
Having these skills can empower people to effectively self-manage their disease
and better identify and prevent episodes of hypoglycaemia and hyperglycaemia
during Ramadan.

SMBG depends on many factors

* Type of diabetes
* Current medication

* Individuals on insulin and/or sulphonylureas must to

monitor their blood , due to increased risk of
hypoglycaemia associated with these medications. *
 Self-monitoring of Blood Glucose

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Fluids and dietary advice

The fasting and feasting nature of Ramadan

can encourage the consumption of large,
carbohydrate-heavy meals, and sugary drinks
and treats that can impact blood glucose levels
potentially increasing the risk of complications
in people with diabetes.
Providing dietary advice and meal planning
can help people with diabetes to follow a
healthy balanced diet during Ramadan,
reducing the likelihood of these complications.
 Exercise
Dr. Khalid

Rigorous exercise should be avoided, particularly during the last hours

of fasting (before When to break the fast
sunset) because it may lead to an increased risk of hypoglycaemia
and/or dehydration [46].
People with diabetes should be encouraged to maintain their normal
physical activity during
Ramadan; they should be reminded that the physical exertions
involved in Taraweeh prayers, Dr. osama
such as bowing, kneeling, and rising, should be considered part of
their daily exercise activities.
Individuals are more likely to achieve HbA1c targets and reduce body
Medication adjustments during
weight when more
fasting
nightly prayers are performed
 Role of educators in pre-Ramadan diabetes education

how often to monitor 8.5

how to alter drug
their blood glucose dosage and timing
during the day

the importance of the importance of

looking out for signs of avoiding strenuous
low blood sugar physical activity
 Ramadan Nutrition Plan (RNP)

Objective
provides a platform designed to help HCPs to
individualise medical nutrition therapy, includes
the diabetes nutrition plan and education and can be a
useful resources for individuals with
diabetes who do not have access to HCPs .

Aims of MNT during Ramadan fasting

1. Individuals with diabetes consume an adequate amount of calories, with balanced

proportions of macronutrients, during the non-fasting period
2. Individuals with diabetes equally distribute their carbohydrate intake among meals to
minimise postprandial hyperglycaemia.
3. Individuals with diabetes and HCPs give consideration to comorbidities such as
hypertension and dyslipidaemia when formulating MNT plans.
 THE PRINCIPLES OF THE RNP
Sugar-heavy desserts should
The consumption of an
be avoided after Iftar and
adequate amount of daily
between meals
calories

Carbohydrates that are low on

Enjoy
Avoid
Meals should be well the GI should be selected,
particularly those high in fibre
balanced
(preferably whole grains).

The “Ramadan plate” method Maintaining an adequate level of

should be used for designing hydration by drinking enough water
and non-sweetened
meals
beverages
 THE PRINCIPLES OF THE RNP

If needed, a healthier snack

such as one piece of fruit, a
Take Suhoor as late as handful of nuts, or vegetables
possible, especially when may be consumed between meals
fasting for longer than 10 hours.

Enjoy
Avoid
Consume an adequate amount iftar should begin with plenty of
of protein and fat at Suhoor as water to overcome dehydration
foods with higher levels of these from fasting, and 1-3 small
macronutrients and lower levels dried or fresh dates to raise
of carbohydrates blood glucose levels.
 RISKS ASSOCIATED WITH FASTING IN PEOPLE WITH
DIABETES

• The main risks reported with fasting are hypoglycaemia and

hyperglycaemia.
• Summer fasting periods can last between 15–18 hours per day
and are often undertaken in hot and humid conditions which can
lead to complications such as dehydration.
• Diabetic ketoacidosis
• Type 1 Diabetes Mellitus (T1DM)
study reported that 48.5% of
participants fasted for the full month
of Ramadan. The incidence of
confirmed and severe
hypoglycaemia was similar to that
prior to Ramadan.
• Type 2 Diabetes Mellitus (T2DM)
study, it was shown that
hypoglycaemia increased
significantly during Ramadan when
compared to before Ramadan,
10.4% - 4.9%.
 Factors that may influence the development
complicated fasting:

A. Ramadan related factors (Length of fasting hours, Season

of fasting, Weather and Geographical location)

B. Diabetes related factors (Type of diabetes, Duration of

diabetes, Diabetic complications, Antidiabetic
therapies,Previous control, hypoglycaemia event and Access
to care)

C. Factors concerning the individual (Age (adolescents and

elderly) , Gender, Occupation , Pregnancy/Lactation, Meal
pattern, Exercise nature/timing
 Risk stratification score

● IDF-DAR Guidelines categorise people with

diabetes into 3 risk groups – high risk, moderate
risk and low risk.

● The resulting score will determine the overall risk

level for an individual with diabetes that is
seeking to fast during Ramadan.
 Risk score calculation example

• 38 years old male patient diagnosed with Type 2

DM since 9 months present today at the clinic
with HbAa1c 7.5 on metformin500 MG and
empagliflozin ,No history of hypoglycemia or
DKA. No ACS. lab: eGFR 99 ml/min
• How much is the score?
• Level of the score? Low/ moderate/ high
• Dose this pt able to fast?
Level of the score

● Individuals who are in the high risk and

moderate risk categorys should not fast.
● Those at the low risk level should be able to
fast.
When to break the fast?
Dose Adjustment for Oral hypo glycemic agent
 Once / twice Daily dose

500/850 mg

Three time daily dose

Metformin

Once dose

Acarbose XR 750 mg
DM medication group

Twice

Pioglitazone
TZDs
15 to 45 mg

liraglutide

GLP-RAS

Semaglutide 0.25–0.5 to 1 mg
dulaglutide 0.75–1.5 mg

SGLT* Empagliflozin 10–25 mg / Dapagliflozin 5-10 mg

SU Glicazide, Glicazide MR, - Glimepiride

Linagliptin 5 mg- Sitagliptin 25-50 to100 mg(1)

DDP4
Vildagliptin 50 mg(1/2)
 Same iftar dose

DM medication group
Short Insulin Omit lunch dose

Insulin Dose Insulin

25-50% suhoor dose

At iftar reduce Dose

Adjustment Long & intermediate

insulin
Once daily
by 25%

Reduce shaour Dose

Twice daily
by 50%
Premixed Insulin
Dose Adjustment
Once dose daily At iftar

Insulin
Normal dose at iftar
Twice daily dose
Reduce shaour Dose
by 50% daily

Omit afternoon dose

Three-time daily dose
Re adjust iftar and
sahoour dose titration
Dose titration