SOUTH ASIAN GUIDELINES FOR MANAGEMENT OF ENDOCRINE DISORDERS IN RAMADAN

Year : 2012  |  Volume : 16  |  Issue : 4  |  Page : 516-518

Fasting guidelines for diabetic children and adolescents

Kiswhar Azad¹, Fauzia Mohsin¹, Abdul Hamid Zargar², Bedowra Zabeen¹, Jamal Ahmad³, Syed Abbas Raza⁴, Samin Tayyeb¹, Sarita Bajaj⁵, Osama Ishtiaq⁶, Sanjay Kalra^7
1 Paediatrics, BIRDEM and Ibrahim Medical College, Dhaka, Bangladesh
² Department of Endocrinology, Advanced Center for Diabetes and Endocrine Care, Srinagar, India
³ Rajiv Gandhi Centre for Diabetes and Endocrinology, J. N. Medical College, Aligarh Muslim University, Aligarh, India
⁴ Endocrinologist, Shaukat Khanum Cancer Hospital and Research Center, Lahore, Pakistan
⁵ MLN Medical College, Allahabad, India
⁶ Endocrinologist, Shifa International Hospital, Islamabad, Pakistan
⁷ BHARTI Hospital and B.R.I.D.E., Karnal, India

Correspondence Address:
Fauzia Mohsin
Associate Professor, Department of Paediatrics, BIRDEM General Hospital-2 (Mohila O Shishu), 1/A, Ibrahim Sharani, Shegun Bagicha, Dhaka-1000
Bangladesh

Source of Support: None, Conflict of Interest: None

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DOI: 10.4103/2230-8210.97998

Abstract

Fasting during the month of Ramadan, the ninth month of Islamic lunar calendar, is obligatory for all healthy adult and adolescent Muslims from the age of 12 years. Fasting starts from early dawn (Sohur/Sehri) till sunset (Iftar). During this period one has to abstain from eating and drinking. Islam has allowed many categories of people to be exempted from fasting, for example, young children, travelers, the sick, the elderly, pregnant, and lactating women. According to expert opinion, patients with type 1 diabetes (type 1 DM) who fast during Ramadan are at a very high risk to develop adverse events. However, some experienced physicians are of the opinion that fasting during Ramadan is safe for type 1 DM patients, including adolescents and older children, with good glycemic control who do regular self-monitoring and are under close professional supervision. The strategies to ensure safety of type 1 diabetic adolescents who are planning to fast include the following: Ramadan-focused medical education, pre-Ramadan medical assessment, following a healthy diet and physical activity pattern, modification in insulin regimen, and blood glucose monitoring as advised by the physician.

Keywords: Adolescent, Ramadan, type 1 diabetes

• Severe hypoglycemia within the 3 months prior to Ramadan
• A history of recurrent hypoglycemia
• Hypoglycemia unawareness
• Sustained poor glycemic control
• Ketoacidosis within the 3 months prior to Ramadan
• Type 1 diabetes
• Acute illness
• Hyperosmolar hyperglycemic coma within the previous 3 months
• Performing intense physical labor
• Pregnancy
• Chronic dialysis

1. Self-monitoring of blood glucose at home.
2. Focus on the causation, early recognition, and emergency management of hypoglycemia, hyperglycemia, dehydration, and impending diabetic ketoacidosis.
3. Meal planning and dietary advice.
4. Timing and intensity of physical activity.
5. Compliance to medications.

1. Preferably undertaken 1-2 months before the fasting month starts.
2. Physical status, glycemic status, and appropriate blood studies.
3. Look for any acute and chronic complications and individual risk stratification to identify those not fit to fast.

1. Ingestion of large amount of foods rich in carbohydrate and fat during Iftar should be avoided.
2. Meal at Sehri should contain complex carbohydrate, as this will delay digestion and absorption (slow-digesting foods). This should be taken as late as possible.
3. Inclusion of fruits, vegetables, lentils, yogurt, cereal (e.g., puffed rice).
4. Fluid should be taken liberally during nonfasting hours.

1. Normal level of physical activity should be maintained.
2. Rigorous exercise during fasting hours should be avoided.

1. Under Al Shariaa and Al Fatwa law, neither blood testing nor administration of insulin is forbidden and neither is considered to invalidate the fasting state. Patients should be encouraged to do frequent home monitoring.
2. Urine should be checked for ketone if blood glucose is high (>15 mmol/L).

1. Patient should break fasting if blood sugar levels are low (<4 mmol/L) or patient experiences signs/symptoms of hypoglycemia and if blood glucose level is >16.7 mmol/L.
2. Patient should avoid fasting on sick days.

Insulin Regimens for Type 1 Diabetic Patients

1. Reduction of basal insulin (e.g., glargine) by 10-20% and further if needed.
2. To take rapid-acting analog (e.g., aspart) with meal.
3. If glucose rises above 15 mmol/L, a correcting dose of rapid-acting insulin should be given.
4. To use carbohydrate counting for meals to match the insulin dose.
5. If long- and rapid-acting insulin analogs are unavailable, it may be sufficient to use intermediate and short-acting insulin instead. ^[2]

References

1.	Al-Arouj M, Assaad-Khalil S, Buse J, Fahdil I, Fahmy M, Hafez S, et al. Recommendations for management of diabetes during Ramadan, Update 2010. Diabetes Care 2010;33:1895-902.   [PUBMED]  [FULLTEXT]
2.	Al-Khawari M, Al-Ruwayeh A, Al-Doub K, Allgrove J. Adolescents on basal-bolus insulin can fast during Ramadan. Pediatric Diabetes 2010;11:96-100.   [PUBMED]  [FULLTEXT]
3.	Salman H, Abdullah MA, Abanamy MA, Al Howasi M. Ramadan fasting in diabetic children in Riyadh. Diabet Med 1992;9:583-4.
4.	Kadiri A, Al-Nakhi A, El-Ghazali S, Jabbar A, Al Arouj M, Akram J, et al. Treatment of type 1 diabetes with insulin lispro during Ramadan. Diabetes Metab 2001;27:482-6.   [PUBMED]  [FULLTEXT]
5.	Jaleel MA, Raza SA, Fathima FN, Jaleel BN. Ramadan and diabetes: As-Saum (The fasting). Indian J Endocrinol Metab 2011;15:268-73.   [PUBMED]  [FULLTEXT]
6.	Al Arouj M, Bouguerra R, Buse J, Hafez S, Hassanein M, Ibrahim MA, et al. Recommendations for management of diabetes during Ramadan. Diabetes Care 2005;28:2305-11.

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