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Sunday, June 24, 2018

Managing Diabetes during the month of Ramadan

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Ramadan is an annual period of fasting, prayer, and giving to charity observed by more than one billion Muslims every year. During this month Muslims fast by avoiding any kind of eating or drinking as well as medications or smoking for certain hours every day.

According to the EPIDIAR(Epidemiology of Diabetes and Ramadan) study on 12,243 Muslims from 13 different countries, approximately 43% of Type 1 Diabetes patients and 79% of Type 2 Diabetes patients fast every year during Ramadan.

What happens to the body during fasting?During a fast, at about eight hours after the last meal, body starts to use energy stores to keep your blood glucose levels normal. For most people this is not harmful, but in diabetes, body cannot use the glucose as well as it should.

With diabetes - especially if on certain tablets or insulin - there are at risk of hypoglycemia (low blood glucose levels). Another challenge that can occur if you have diabetes, is the risk of high sugars following the larger meals that are eaten before and after fasting (at Sohur and Iftar), which can lead to health problems in the short and long term.

Understanding the risks:At least 3 months ahead to Ramadan, the patients with diabetes should seek advice from the endocrinologist or diabetologist for the preparation of fasting and adjustment suitable drugs. Also risk assessment is very much essential.

Fasting is not recommended in the following situations:
*   Type 1 diabetes;
*    Frequent hypoglycaemia or hypo unawareness (i.e. not being aware of it when you're having low blood sugar);
*    Diabetic ketoacidosis within the past six months;
*    Hospital admission for very high blood glucose within the last six months;
*    Severe hypoglycaemia (low blood glucose) in the past six months;
*    If you have poor control of your diabetes - HbA1c is greater than 75 mmol/mol (9%);
*    If you have complications of diabetes such as problems with kidneys, heart or poor vision;
*    If you have an acute illness, including a diabetic foot infection or foot ulcer;
*    If you are pregnant.

Necessary measures for safely fasting: It is important that to start preparation as before as possible. The responding expert will offer the appropriate education. That will start with blood glucose monitoring, blood sampling, and injections do not invalidate the fast.

During the initial days of fasting patients need to test blood glucose at 7am, in the afternoon, before and 2 hours after fasting, then a few times during the days. Patients need to break the fast if blood glucose levels fall too low or rise too high. Generally, levels below 4 mmol/L (or 70 mg/dL), or above 16 mmol/L (or 300 mg/dL) are considered unsafe. It is very important, however, that you discuss with your diabetes care team to find out what levels are safe for you.

Diet and exercise advice:Dates sweats and milk are a traditional choice for breaking the fast. However, for people with diabetes, remember that dates are rich in rapidly absorbed sugar, so it's best to limit as much as possible. The common practice of ingesting large amounts of foods rich in carbohydrate and fat, especially at the sunset meal, should be avoided.

Distributing calories over two to three smaller meals during the no-fasting interval - rather than eating one big meal - may help to prevent excessive hyperglycemia (high blood sugar) after you eat.Symptoms felt with high blood sugar and low blood sugar are sometimes the same, making it difficult to recognize the actual condition.

General healthy diet advice should be followed, including eating at least five fruits and vegetables a day. It is recommended to choose foods that help promote a slow steady rise in blood sugar in suhur, such as whole grain bread, whole grain low sugar cereals, beans and lentils. These foods are slowly digested, which can help to maintain your blood glucose levels and may make you feel less hungry.

Adequate fluid intake (water and sugar-free drinks) when breaking the fast is crucial to prevent the risks of dehydration, kidney failure, and blood clots. Physical activity is encouraged, but reduced exercise in required especially during day time.

Advice for people with type 1 diabetes: The general advice for those with type 1 diabetes is that they should not fast; however, in some circumstances, they may be able to come up with a safe plan with the help of their diabetes health care providers. Prior to Ramadan, they should receive adequate training and education, particularly with respect to self-management and insulin dose adjustment.

Advice for people with type 2 diabetes: If diabetes is managed by diet or certain oral medications such as metformin or pioglitazone, fasting may be of less risk. If the patient is on any other tablets or injections you need to speak to diabetes expert as the dose and timing of medication should be reviewed and adjusted.

Blood pressure and cholesterol treatment: Dehydration and a tendency towards low blood pressure may occur with fasting during Ramadan, especially if the fast is prolonged. Consultation with cardiologist may help decrease the risk.

-----Dr Shahjada Selim
MBBS, MD (Endocrinology & Metabolism),FACE (USA)
Assistant Professor
Department of Endocrinology
Bangabandhu Sheikh Mujib Medical University, Dhaka

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