Heather Knox

Urban Health Today

<p>Adherence to the religious customs of Ramadan presents a unique set of challenges for Muslim patients with diabetes because of the effects of prolonged fasting and altered meal patterns on blood glucose levels. For Muslims worldwide, Ramadan is considered one of the holiest months of the year, observed by fasting and communal prayer.<sup>1</sup> Adults who are not exempted from fasting because of pregnancy, breastfeeding, menstruation, illness, or age fast from dawn until sunset—typically 11 to 16 hours for 29 to 30 days.</p>
<p>Several studies presented at the American Diabetes Association’s 85th Scientific Sessions investigated topics related to the management of diabetes during Ramadan. Topics ranged from technology—including a smartphone app and different insulin delivery systems—to the psychologic impact of hypoglycemia during fasting. This article features five noteworthy American Diabetes Association (ADA) abstracts focusing on improving outcomes for patients with diabetes who practice fasting during Ramadan.</p>
<h2>Experiences Navigating Ramadan With Diabetes</h2>
<h3>Value of Tailored Insulin Regimens</h3>
<p>A multicenter study evaluated whether use of glargine 100, glargine 300, and degludec safely managed glycemic control for patients with type 1 diabetes who fasted during Ramadan.<sup>2 </sup>The study included 222 patients and observed continuous glucose monitoring (CGM) and survey data. CGM data monitored during this study included time in range (TIR), average glucose, glucose variability, and hypoglycemic events. Researchers observed that patients treated with glargine 100 had better TIR but more hypoglycemia. Glargine 300 was shown to minimize hypoglycemia but had more hyperglycemia. Degludec maintained consistent glucose levels with fewer hypoglycemic events.</p>
<h3>Fear of Hypoglycemia After Ramadan</h3>
<p>According to one study, experiencing severe hypoglycemia during Ramadan was associated with an increased fear of hypoglycemia <em>after</em> Ramadan.<sup>3</sup> The survey study evaluated 159 patients’ fasting experience, glycemic control via CGM, and their fear of hypoglycemia. On the Hypoglycemia Fear Survey (HFS-II), 57% of participants reported a high sense of worry on the HFS-Worry (HFS-W) subscale (HFS-W ≥ 0.92). CGM metrics were worse among participants with a higher score on the HFS-Behavior (HFS-B) subscale (HFS-B ≥ 1.85). Automated insulin delivery (AID) system users had the lowest prevalence of high HFS-B compared with those using other treatment modalities.</p>
<h2>Diabetes Technology Use During Ramadan</h2>
<h3>App Helps Maintain Fasting Blood Glucose</h3>
<p>Another study from the ADA evaluated the ability of the smartphone application My Dose Coach (MDC) to safely titrate insulin doses for patients with type 2 diabetes who fasted during Ramadan.<sup>4</sup> One hundred and six patients were included in this study. The basal insulin dose to fasting blood glucose (FBG) target in this study was 70 to 130 mg/dL. For patients with a pre-Ramadan FBG less than 130 mg/dL, doses were proactively reduced by 20% at the start of Ramadan. For patients with a pre-Ramadan FBG greater than or equal to 130, this dose was not adjusted. The MDC app guided titration in both groups based on their FBG before sunset. In both groups, the proportion of patients with FBG of 70 to 130 mg/dL was maintained throughout Ramadan. Neither group had any case of an FBG below 70 mg/dL.</p>
<h3>Automated Insulin Devices Improve Patient Experience</h3>
<p>Results from a dual-center, randomized controlled trial showed that AID systems enhanced patients’ glycemic control and safety, as well as their ability to adhere to fasting during Ramadan.<sup>5</sup> The study compared AID systems with open-loop insulin delivery systems among patients with type 1 diabetes who were fasting during Ramadan. Outcomes considered in this study included difference in TIR during Ramadan, as well as time below range (TBR), time above range, and a composite outcome of TIR greater than or equal to 70%, TBR less than 5%, and 2 or fewer days of breaking the fast.</p>
<h3>Open-Source Versus Commercial Automated Insulin Delivery</h3>
<p>A multicenter study from Saudi Arabia compared the efficacy and safety of open-source AID (OS-AID) and commercial AID (C-AID) systems for patients with type 1 diabetes fasting during Ramadan.<sup>6</sup> Researchers also looked at fear of hypoglycemia in patients using these devices during Ramadan fasting. One hundred and fourteen patients participated in the study. Seven used OS-AID and 107 used C-AID systems. OS-AID systems were as effective in maintaining glucose levels within the target range as C-AID systems. There were no significant differences between groups in the number of days fasting was broken because of diabetes or in patients’ fear of hypoglycemia after Ramadan.</p>
<div class="post-references"><h3>References</h3><ol>
<li>Islamic Networks Group. <a href="https://ing.org/resources/for-all-groups/calendar-of-important-islamic-dates/ramadan-information-sheet/">Ramadan Information Sheet</a></li>
<li>American Diabetes Association’s (ADA’s) 85th Scientific Sessions. <a href="https://diabetesjournals.org/diabetes/article/74/Supplement_1/831-P/160216/831-P-Comparison-of-Glargine-100-Glargine-300-and?searchresult=1">Abstract 831-P</a>.</li>
<li>American Diabetes Association’s (ADA’s) 85th Scientific Sessions. <a href="https://diabetesjournals.org/diabetes/article/74/Supplement_1/922-P/160497/922-P-Fear-of-Hypoglycemia-after-Ramadan-Fasting?searchresult=1">Abstract 922-P</a>.</li>
<li>American Diabetes Association’s (ADA’s) 85th Scientific Sessions. <a href="https://diabetesjournals.org/diabetes/article/74/Supplement_1/1045-P/159616/1045-P-Use-of-a-Smartphone-Application-for-Basal?searchresult=1">Abstract 1045-P</a>.</li>
<li>American Diabetes Association’s (ADA’s) 85th Scientific Sessions. <a href="https://diabetesjournals.org/diabetes/article/74/Supplement_1/926-P/160493/926-P-Automated-Insulin-Delivery-vs-Open-Loop?searchresult=1">Abstract 926-P</a>.</li>
<li>American Diabetes Association’s (ADA’s) 85th Scientific Sessions. <a href="https://diabetesjournals.org/diabetes/article/74/Supplement_1/923-P/160496/923-P-Fasting-Experience-Glycemic-Control-and-Fear?searchresult=1">Abstract 923-P</a>.</li>
</ol>
</div>

<p>Adherence to the religious customs of Ramadan presents a unique set of challenges for Muslim patients with diabetes because of the effects of prolonged fasting and altered meal patterns on blood glucose levels. For Muslims worldwide, Ramadan is considered one of the holiest months of the year, observed by fasting and communal prayer.<sup>1</sup> Adults who are not exempted from fasting because of pregnancy, breastfeeding, menstruation, illness, or age fast from dawn until sunset—typically 11 to 16 hours for 29 to 30 days.</p><p>Several studies presented at the American Diabetes Association’s 85th Scientific Sessions investigated topics related to the management of diabetes during Ramadan. Topics ranged from technology—including a smartphone app and different insulin delivery systems—to the psychologic impact of hypoglycemia during fasting. This article features five noteworthy American Diabetes Association (ADA) abstracts focusing on improving outcomes for patients with diabetes who practice fasting during Ramadan.</p><h2>Experiences Navigating Ramadan With Diabetes</h2><h3>Value of Tailored Insulin Regimens</h3><p>A multicenter study evaluated whether use of glargine 100, glargine 300, and degludec safely managed glycemic control for patients with type 1 diabetes who fasted during Ramadan.<sup>2 </sup>The study included 222 patients and observed continuous glucose monitoring (CGM) and survey data. CGM data monitored during this study included time in range (TIR), average glucose, glucose variability, and hypoglycemic events. Researchers observed that patients treated with glargine 100 had better TIR but more hypoglycemia. Glargine 300 was shown to minimize hypoglycemia but had more hyperglycemia. Degludec maintained consistent glucose levels with fewer hypoglycemic events.</p><h3>Fear of Hypoglycemia After Ramadan</h3><p>According to one study, experiencing severe hypoglycemia during Ramadan was associated with an increased fear of hypoglycemia <em>after</em> Ramadan.<sup>3</sup> The survey study evaluated 159 patients’ fasting experience, glycemic control via CGM, and their fear of hypoglycemia. On the Hypoglycemia Fear Survey (HFS-II), 57% of participants reported a high sense of worry on the HFS-Worry (HFS-W) subscale (HFS-W ≥ 0.92). CGM metrics were worse among participants with a higher score on the HFS-Behavior (HFS-B) subscale (HFS-B ≥ 1.85). Automated insulin delivery (AID) system users had the lowest prevalence of high HFS-B compared with those using other treatment modalities.</p><h2>Diabetes Technology Use During Ramadan</h2><h3>App Helps Maintain Fasting Blood Glucose</h3><p>Another study from the ADA evaluated the ability of the smartphone application My Dose Coach (MDC) to safely titrate insulin doses for patients with type 2 diabetes who fasted during Ramadan.<sup>4</sup> One hundred and six patients were included in this study. The basal insulin dose to fasting blood glucose (FBG) target in this study was 70 to 130 mg/dL. For patients with a pre-Ramadan FBG less than 130 mg/dL, doses were proactively reduced by 20% at the start of Ramadan. For patients with a pre-Ramadan FBG greater than or equal to 130, this dose was not adjusted. The MDC app guided titration in both groups based on their FBG before sunset. In both groups, the proportion of patients with FBG of 70 to 130 mg/dL was maintained throughout Ramadan. Neither group had any case of an FBG below 70 mg/dL.</p><h3>Automated Insulin Devices Improve Patient Experience</h3><p>Results from a dual-center, randomized controlled trial showed that AID systems enhanced patients’ glycemic control and safety, as well as their ability to adhere to fasting during Ramadan.<sup>5</sup> The study compared AID systems with open-loop insulin delivery systems among patients with type 1 diabetes who were fasting during Ramadan. Outcomes considered in this study included difference in TIR during Ramadan, as well as time below range (TBR), time above range, and a composite outcome of TIR greater than or equal to 70%, TBR less than 5%, and 2 or fewer days of breaking the fast.</p><h3>Open-Source Versus Commercial Automated Insulin Delivery</h3><p>A multicenter study from Saudi Arabia compared the efficacy and safety of open-source AID (OS-AID) and commercial AID (C-AID) systems for patients with type 1 diabetes fasting during Ramadan.<sup>6</sup> Researchers also looked at fear of hypoglycemia in patients using these devices during Ramadan fasting. One hundred and fourteen patients participated in the study. Seven used OS-AID and 107 used C-AID systems. OS-AID systems were as effective in maintaining glucose levels within the target range as C-AID systems. There were no significant differences between groups in the number of days fasting was broken because of diabetes or in patients’ fear of hypoglycemia after Ramadan.</p><div class="post-references"><h3>References</h3><ol>
<li>Islamic Networks Group. <a href="https://ing.org/resources/for-all-groups/calendar-of-important-islamic-dates/ramadan-information-sheet/">Ramadan Information Sheet</a></li>
<li>American Diabetes Association’s (ADA’s) 85th Scientific Sessions. <a href="https://diabetesjournals.org/diabetes/article/74/Supplement_1/831-P/160216/831-P-Comparison-of-Glargine-100-Glargine-300-and?searchresult=1">Abstract 831-P</a>.</li>
<li>American Diabetes Association’s (ADA’s) 85th Scientific Sessions. <a href="https://diabetesjournals.org/diabetes/article/74/Supplement_1/922-P/160497/922-P-Fear-of-Hypoglycemia-after-Ramadan-Fasting?searchresult=1">Abstract 922-P</a>.</li>
<li>American Diabetes Association’s (ADA’s) 85th Scientific Sessions. <a href="https://diabetesjournals.org/diabetes/article/74/Supplement_1/1045-P/159616/1045-P-Use-of-a-Smartphone-Application-for-Basal?searchresult=1">Abstract 1045-P</a>.</li>
<li>American Diabetes Association’s (ADA’s) 85th Scientific Sessions. <a href="https://diabetesjournals.org/diabetes/article/74/Supplement_1/926-P/160493/926-P-Automated-Insulin-Delivery-vs-Open-Loop?searchresult=1">Abstract 926-P</a>.</li>
<li>American Diabetes Association’s (ADA’s) 85th Scientific Sessions. <a href="https://diabetesjournals.org/diabetes/article/74/Supplement_1/923-P/160496/923-P-Fasting-Experience-Glycemic-Control-and-Fear?searchresult=1">Abstract 923-P</a>.</li>
</ol>
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Several studies presented at the American Diabetes Association’s 85th Scientific Sessions investigated topics related to the management of diabetes during Ramadan. 