Ramadan Fasting Related Diabetes Education for Public Health

Diabetes prevalance is incredibly increasing all around the world, yet many people with diabetes (PWD) are unaware and considerable number of them are unattentive, having way before the desired levels of metabolic control (1). Muslim geography especially the Middle-East and North Africa (MENA) has also grown diabetes population together with South and South-East Asia [1-4]. Most PWD are associated with obesity so that the concept of diabesity is fairly appreciated by many clinicians, today [5]. Intermittent fasting (IF) became popular in order to get rid of extra pounds by many PWD for this regard. Meanwhile, Ramadan Intermmittent Fasting (RIF) is a different one since rather than IF -which is an individualized preference with not that much having strict rules such as a fixed month fasting observance on that year-. Ramadan is a religious holy month for muslim individuals and fasting is obligatory for those healthy people over the age of puberty with a month-long duration (29-30 days according to lunar calender), starts before dawn and ends with dusk (sunset) with an iftar meal [3,4]. Although, Quran clearly exempts sickness from fasting [6] epidemiologic studies such as EPIDIAR [7], CREED [8], MENA type 1 [9] and MENA type 2 Studies [10] carried out in many countries with multiple investigator sites revealed that tremendous amount of PWD fasted during this holy month (Ramadan). Even during curfew, amidst Covid-19, a telephone survey conducted for both type 1 and type 2 diabetes -reaching out to more than tenthousand people, the prevalance of fasting exercise since from the beginning of the new millenium towards pandemic was having an increasing trend [11-14].

Before aforementioned epidemiologic studies [7,8] there was no clear definition of international guidelines [3,4,15] so as to say whom to fast or not (16). All of these observational studies provided that the healthcare professionals (HCPs) were providing their own clinical judgements so that there was no unity for decision making for PWD whether or not to allow fast among different countries and regions of the world. RIF exercise was being performed even muslim not pre-dominated countries as well, such as United Kingdom, France and Canada. Canada, i.e.; may have a special consideration since when RIF occurs during hot summer holidays, long fasting hours in the northern hemisphere of the world may become challenging, thus leading to the risk of dehydration in PWD (4). All of these needed to organize Ramadan Specific structured Diabetes Education (RSDE) program for both HCPs and PWD and even their relatives [17-25]. One of the studies -READ Studycarried out, revealed that such specific education decreased the hypoglycaemic events fourfold during Ramadan as a comparison to those without education [17]. This study was rewarded later on by British Diabetes Society and Diabetes Education and Study Group (DESG) of European Association for the Study of Diabetes (EASD) in 2008. Education should include for both types of diabetes including training for self-monitoring of the blood glucose (SMBG) [23,24].

Other than RSDE, holy month is such a great opportunity for PWD since many already are having lack of planned and organized diabetes education since from the diagnosis. Ramadan may also be helpful to cease smoking [4] thoroughly, since already cigarette breaks fasting when smoked during fasting hours that break may give rise leave that habit even after the holy month. RSDE should include Ramadan Nutrition Plan (RNP) also [4], although it is variable among the countries. Eating habits will change during fasting and without knowledge and training, it may become troublesome leading to both hypoglycaemia (less than 70 mg/dl) and significant hyperglycaemia (over 300 mg/dl) which are both consensensus statements owing to guidelines to break the fast [3,4]. RNP is no more three main meals and three snacks as before RIF, since during fasting there are 2 main meals only (Sahoor; early breakfast before sunrise & Iftar; meal at dinner). As PWD are already prone to dehydratation, water consumption between iftar and sahoor should be encouraged. In order to get rid of hypoglycaemia having sahoor meal is important and postponing day exercise later in the evening such as a specific one already performed by many muslims unique to the holy month called the teraweeh prayers [4]. During iftar which is a sunset meal, dinner becomes like a festival with a number of foods prepared, so fasting converts into feasting that may give rise to significant hyperglycaemia afterwards with high glycaemic index food, deserts, sweetened liquids, etc. that might be consumed unless carefully RNP before Ramadan was taught by the HCPs.

Other than RNP, medications being used may need to be carefully evaluated and adjusted preferably six to eight weeks before the beginning of Ramadan. Especially for those on sulfonylureas [3,4,26,27] and insulin preperations, hypoglycaemic events are more likely to be seen rather than with other anti-diabetic medications [27-30]. Meanwhile, not all sulfonylureas and insulins are the same. Second generation sulfonylureas likely to cause less hypoglycaemia, and analogue insulins have less occasions than human insulins and long-acting analogues are better and mixed insulins [3,4]. Even among long-acting insulin analogues, second generation insulin glargine U300 had been found both safe and effective for PWD who exercise RIF (28). Mobile applications and web services are being used succesfully these days [31], and artificial intelligence equipped tools such as insulin pumps can also be used successfully during RIF and with help of RSDE for PWD fasting Ramadan will be even less eventfully [32-39]. Other class of drugs like biguanides, glinides, alpha glucosidase inhibitors, glitazones, di-peptidyl peptidase-4 inhibitors (DPP-4i), sodium glucose co-transporter-2 inhibitors (SGLT-2i), glucagone like peptide-1 receptor analogues (i.e; exenatide, liraglutide, lixisenatide), alone or with dual activity (i.e; tirzepetide, semaglutide) may lead to less events than above mentioned group of drugs [3,4,40-51].

In conclusion; RIF without education may become a nightmare owing to detrimental consequences of both hypoglycaemia and hyperglycaemia. RSDE may help alleviate these consequences so that before each Ramadan should be performed according to the guidelines with well-trained also HCPs.

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