Fasting in the holy month of Ramadan is one of the five pillars of Islam and is considered a religious obligation for Muslims. While fasting is not required for people with diabetes, one study found that almost 80 per cent of all Muslims with type 2 diabetes tend to fast for at least 15 days.
In this case, they are at a higher risk of complications such as hypoglycaemia (low glucose), hyperglycaemia (high glucose), and ketoacidosis due to changes in physiological parameters such as eating patterns and circadian rhythms. Therefore, healthcare professionals are responsible for delivering accurate information regarding fasting and diabetes. The foundation for safely managing diabetes during Ramadan is patient education, including instructions on expected risks, medication adjustment, glucose monitoring, nutrition, and exercise.
In an interview with Dr Milena Caccelli, Endocrinologist at GluCare Integrated Diabetes Center, we discuss how pre-Ramadan risk assessments and benefits are key to ensuring a safe fasting experience for diabetic patients.
What type of patients qualify as candidates for pre-Ramadan risk assessment? Tell us about the process, how GluCare provides care outside the clinic, and the role of digital health in this aspect.
We strongly advise receiving your pre-Ramadan risk stratification and counselling from your healthcare professionals before Ramadan.
Our team uses Digital Therapeutics and connects patients to a remote monitoring platform. We look at trends, intervene earlier, and provide better predictions to avoid fluctuating blood sugars during Ramadan. Digital devices such as a Continuous Glucose Monitor (CGM) and wearables can help you and your care team better monitor and adjust your treatment as necessary.
Combining in-clinic visits and a 24/7 monitoring platform, in conjunction with regular remote engagement with our care team, allows us to create individualised management plans ‘pre-Ramadan’ for each patient. During Ramadan, we will provide individualised nutritional plans and provide you with insights and advice on medication adjustment without physically visiting the facility for each adjustment. You will also receive regular feedback about your glucose values via our chat function. After Ramadan, we discuss medication and regime readjustments back to your normal routine.
How can CGM help with ensuring patient wellbeing as they observe Ramadan? How is the data received and plans adjusted by specialists?
Monitoring glucose is crucial during Ramadan. Many hours of fasting can lead to a high risk of developing hypoglycaemia and hyperglycaemia. A continuous glucose monitor (CGM) reduces the number of finger pricks by providing continuous glucose data, which facilitates the monitoring process. With real-time data, patients can act based on glucose trends. For example, if the data shows lowering glycaemic values, the patient should break their fast and correct the hypoglycaemia by eating accordingly. In addition, a care team also monitors this data and can message the patient to adjust medication (reducing, for example, the dosage of the oral tablets, or reducing insulin units) during extended hypoglycaemic events.
Dr Milena Caccelli, Endocrinologist at GluCare Integrated Diabetes Center
Why is it crucial to create personalised plans for patients to ensure fasting during Ramadan is risk-free?
Risk stratification is an essential aspect of all diabetes and Ramadan recommendations. The significant risks, hypoglycaemia and hyperglycaemia are faced by people with diabetes daily; however, studies have shown that fasting may increase the chances of these events occurring. With the pre-Ramadan assessment and screening, we show our patients their risk for complications during Ramadan and how to avoid them.
It is worth highlighting that the initial risk assessment can change, for example, if the risk is modifiable such as glycaemic control, frequency of SMBG, or with the development of a new complication; in these circumstances, the risk level will need to be adjusted accordingly. An individual’s Ramadan experience may vary every year, and, therefore, there is a need for a renewed risk stratification annually to make it a safe and happy experience for all.
The GluCare Ramadan programme, and digital therapeutics platform allows patients to manage diabetes fast, safely, and engagingly throughout the holy month.
Telehealth and digital advancement are proving to be key in accelerating improvements in healthcare. How do features such as chat support create an opportunity for data retrieval and ensure successful patient outcomes?
By continuously monitoring patients, our team can avoid clinical inertia common in usual care, and we can practice a more proactive approach rather than a reactive one. We do not need to wait for the regular three-month intervals to see a patient physically to modify or adjust the treatment plan and guide patients regarding medication side effects.
Are there any benefits for patients who suffer from chronic illnesses, such as diabetes, when they fast? What is the patient profile of those who can lower their insulin levels through fasting?
There are many beneficial effects of fasting that are supported by observational studies. These found that food caloric restriction and intermittent fasting are associated with deceleration or prevention of most chronic inflammatory diseases such as metabolic diseases, pain syndromes, and psychosomatic disorders. There are some results regarding the role of fasting in weight loss and maintenance loss.
Epidemiology says that grazing throughout the day increases the odds of having obesity by 57 per cent in humans. Every three hours increase in the daily duration of eating increases the risk of pre-diabetes and diabetes by 20 per cent. Regarding the frequency and timing of meals in preventing cardiovascular disease, the American Heart Association states that intermittent fasting can be used as a strategy for weight loss and eating more calories during the day. Overnight fasting is a practice recommended for most individuals.
Fasting periods (beyond the average time between meals) promote cellular repair, improve insulin sensitivity, increase human growth hormone levels, and promote longevity and disease protection. Therefore, for obese patients with type 2 diabetes, some form of intermittent fasting will improve insulin resistance.