May 01, 2017 Ramadan and your patients

[00:00:03] Hi everyone and welcome to our webinar. Ramadan and diabetes for health care providers. My name is Stephanie Boutette and I will be your host today. To start off, I would like to draw your attention to the survey at the top right hand section of your screen in order to better serve your needs. We kindly ask that you provide us with your input by completing the short survey towards the end of the presentation. Throughout the presentation you will have the opportunity to type in the Q and A box located at the bottom right of your screen. We ask that you use this box for any questions you have along the way and our presenters will be happy to answer at the end of the presentation. The presentation itself will be about 45 minutes in length with five to 10 minutes at the end for questions. It is important to note that this will be recorded and posted to the Diabetes Canada website at a later date. Now as a special treat we have with us the Diabetes Canada President and CEO to welcome our first speaker.

[00:01:00] Hello everyone. Thank you very very much for being on this webinar. I have met Dr. Mohamed Hussein in Europe when I was travelling on behalf of Diabetes Canada working with the International Diabetes Federation on what was called the Berlin Declaration on Early Action. And at that time I determined it would be very interesting to have him join us to speak about Ramadan and our Muslim population, as you know one of the fastest growing populations in Canada. And for those that may not know that the population will fast over Ramadan for approximately 17 hours a day without food and water. And so therefore what are the kinds of opportunities for people with diabetes to get through Ramadan.

[00:02:06] Mohammed was appointed as a consultant endocrinologist at B.C. University Health Board in the United Kingdom. He's an Honorary Senior Lecturer and the associate director of postgraduate diabetes education at Cardiff University in the UK. He's currently working as a consultant in endocrinology in Dubai hospital UAE and has also worked with the Joslin Center for Diabetes at Harvard Medical School. He's the chair of the diabetes and Ramadan International Alliance DA for short DLR which has been set up in collaboration with the IDF Mena and Africa regions the study group of the e a SD and the Gulf group for the Study of Diabetes is the co-author and recommendations on this subject for the IDF in 2016. The ACA in 25 and 2010 and the BMJ in 2010 and participated as the first author or coauthor in almost 50 papers has presented more than 40 oral presentations at international meetings. I'm also very pleased to announce that Dr. Hassanein has agreed to work with Diabetes Canada in this area. He is also the co recipient of the Diabetes UK structured education first prize in 2018 and 2019 as well as the European Association study of diabetes education prize in 2009. Dr. Hassanein has also helped develop the Wales Diabetes Guidelines and is an examiner with the Royal College of Physicians for the RCMP clinical exam. He has worked closely associated with a number of educational projects and has provided e-diabetes learning to many countries in collaboration with the university pneumatic francophone Majed. And so without further ado I would like to welcome the good doctor to our webinar.

[00:04:14] Thank you very much Rick and thanks for Diabetes Canada for this opportunity and to invite me to be with you all on this webinar. I look forward to your comments and your questions. And both myself and Vivian will try as much as possible to answer all your questions. Much of what I would present to you today is related to the IDF diet guidelines which as you can see here is the website which you can review the guidelines and have a free download of the PDF. It's been developed in collaboration with a large number of experts across the globe. If you wish to have a brief summary of it, it has just been published in Diabetes Research and Clinical Practice and it is also a free downloads. Now as previously mentioned in Canada as well as across many parts of the globe, the Muslim population is about 23 percent of the global population specifically about 1.6 billion Muslims worldwide. When you look into the prevalence of diabetes in these countries and it's a fast growing prevalence of diabetes you would come to the figure of approximately one hundred and forty eight million Muslim with diabetes across the globe. And they're fasting hours vary tremendously. From as low as 15 in some countries, there are over 17 or close to 18 hours of fasting. Now as you can see from this chart in dark blue is the number of people at the beginning of the month with the intention to fast, and that's over 94 percent. But how many are actually able to fast the full month of Ramadan. And that's in the dark brown or red at 67 percent. But while the intention is there for everyone, not everyone is able to fast every day because of health conditions. It's further interesting when you see the differences between one country and the other such as in Morocco and Algeria. These are two very neighboring countries. The advice in one country such as in Morocco is different from the advice in Algeria. And consequently this took the number of people who were able to complete the month fast was very different in both. Now who's right and who's wrong. It's difficult to tell. And that's part of the lack of strong evidence based medicine that we all strive for. Ramadan fasting makes a huge change to the individual lifestyle. When a person is fasting Ramadan there is a change from the pattern of three meals a day and sleeping at night to possibly two meals a day and with interrupted sleep at night. This interrupted sleep would make so many people have different physiological changes and different hormonal changes. The different quality of sleep as well would have an impact on their hormones and on their physiology, which could lead to a change in pattern. If you were to look into the fasting hours based on continuous glucose monitoring. So as you can see here it was continuous of course monitoring in yellow fasting. You can see there's a dip before the time for Iftar. Iftar is the name for the main meal. At that time, there's a high surge of blood glucose levels. While in non fasting hours, there is the variation from morning to lunchtime to evening which obviously you're all familiar with.

[00:08:42] So satiety and hunger is quite also interesting. If you look into our hunger. When do we feel hungry. At breakfast time, at lunchtime at a dinner and it doesn't change too much. Now if you look into fasting Ramadan and men and women and the hunger. So in light blue is this hunger status of men as the hours pass by in a day in the early of Ramadan. And as we approach the later evening the hunger of individual gets higher and higher. And that does not change in the later part lack of part of Ramadan. So don't try to go shopping and buy your foodstuff in the late afternoon, if you're fasting and a male. If you're a female you can see it's tough at the same level as men. But for some reason satiety in a woman settles as the months pass by. So you can see here by day 24 that the hunger of woman is less than the hunger of men when they are fasting. I don't really know what is the reason for this physiological change but it's certainly something that's been noted in the studies mentioned with the references below on the slide. So what are the risks of fasting during Ramadan. I think the most important one is hypoglycemia followed by hyperglycemia with or without diabetic ketoacidosis. The theoretical risk of dehydration or thrombosis is probably there and stronger nowadays with many countries experiencing Ramadan in the long hot summer months such Canada.

[00:10:38] So what do we really need to do and how can we see this risks from one country to another country. So the epidemiological studies looked into hypoglycemia and we first had the PIDAAR study several years ago and that showed us that there is an increased risk of severe hypoglycemia in both type 1 and type 2 diabetes for people wishing to fast. More modern studies such as the CREED study and the prospective study in Pakistan did not show us a significant rise in severe hypos but in symptomatic hypoglycemia. For hyperglycemia, the trend also has been there to see some increase in symptomatic hyperglycemia in more modern studies. But the severe one that leads to hospitalization has been less in the countries where the data have been collected. Unfortunately none of these data did include Canada. And that's something that we need to overcome in the future. What about diabetic ketoacidosis. Well we did this study in United Emirates and the United Arab Emirates and we've repeated the study again. As you can see from the following study from four different countries and we specifically looked into admissions to hospitals with diabetic ketoacidosis during the month preceding Ramadan, the month of Ramadan and the month following Ramadan. And as you can see from the conclusion of the publication is there's been a trend of an increase in diabetic ketoacidosis in comparison to pre Ramadan and to the previous month as well. So how do we as health care professionals quantify for the risks. The first aspect is to differentiate between the type of diabetes. A person with type 1 diabetes is certainly very different from a person with type 2 diabetes. The type of medication precisely for example I've given to you, if I'm on a diet is different than if I'm having insulin even though maybe both examples were for a person with type 2 diabetes. Then it is the individual hypoglycemia risk. We know that many of our people with diabetes have reduced or have lost the hypoglycemia awareness and that makes them at a much higher risk compared to others.

[00:13:15] The comorbidities and complications. An example of this if I have a kidney complication, renal problems, then the risk of accumulation of the drug will be higher and consequently the risk of hypoglycemia could be higher. Similarly the fluid balance for the day when I have a kidney problem or heart problem would be important to take into account. The social circumstances are also quite important. Assuming that we have twins one of them works in an air-conditioned office and the other one is in the heat and a physical job. Then both have a very different risk of having hypoglycemia. And then last but not least is my own previous experience last Ramadan. If I come to you as a health care professional and my control has been good for the previous Ramadan and I'm monitoring well and I have good hypo awareness then regardless of my type of treatment or type of diabetes that would need to be taken into account.

[00:14:18] Let's not forget that Ramadan is not a scientific issue. It is also as much a religious issue. And we must have unification of opinion between the health care professionals and the community leaders. This unification will reduce the confusion of the person and certainly it is a subject that needs the collaboration of the media, the journalists and anyone in the community with interest in diabetes as well as Ramadan.

[00:14:53] I'm delighted that the risk categories that we have established for the idea of Ramadan has been agreed upon by the Mufti of Egypt which is part of the Al Azhar University. We have this guidelines now like a traffic light system. Red, amber or green. Now while this is classification that is jointly between science and religion, it's important to remember that our Muslim people come from different backgrounds and it's important to have your local religious recommendations and agreement on these issues as well.

[00:15:35] Here is the different levels of risks. I'm not going to go through the in-depth point by point of them. As I mentioned before the full document is a free download online from the IDF or from the Diabetes Research and Clinical Practice website. But they would all be points of common sense in those with very high risk or those with high risk or indeed those with moderate or low risk. These all tend to be people with type 2 diabetes on oral therapy, lifestyle measures or on basal insulin. But do remember that the religious advice for these as well it is for the patient himself or herself to identify the degree of burden of the diabetes on the ability to fast or not.

[00:16:27] At the end of the day it's a discussion and it's something related to education. A person with type 2 diabetes, an elderly person or a pregnant woman are all considered as part of the high risk category. But I would like to comment on the elderly. Elderly is not issue with a specific age. If I am in this specific age in your community is considered as a definition of elderly you need to remember that I might have fasted for many many years and it's more important to look into my health in general, my comorbidities, the different medications I'm on and consequently my ability to safely fast or not rather than a specific age category.

[00:17:13] What about pregnancy. A pregnant woman in Islam is a person could not to fast if she wished. A pregnant woman with diabetes have two reasons one is diabetes and the other one is the pregnancy itself. And it is very important to remember that the target during pregnancy is not only to avoid hypoglycemia but also to avoid post prandial hyperglycemia, which is something difficult to achieve after fasting for 17 or 18 hours such as in Canada. So reminding our pregnant ladies with diabetes about these issues and at the end of the day, you could always make up for these days after the pregnancy is over.

[00:18:01] So education is key for any person with diabetes wishing to fast Ramadan. Education regarding the risk quantification, the timing of glucose monitoring and the frequency of the glucose monitoring, the different types of foods and drinks, the portions control, the fluid intake and spreading the fluid intake across many hours rather than the last minutes before it is time to start the fast. Ramadan is not a month for sedentary lifestyle but indeed if I would wish to do strenuous exercise then it is best to be done in the evening if possible. There's a need for adjustment in the medication, the type of medication, the dose and the timing and most importantly there is a need for the person with diabetes to recognize when to break the fast. All this is quite important. Ramadan nutrition planned, have ten different principles. I'm not going to go through them because the session following my session will specifically answer most of these issues and they are all very important common sense. I would like just to comment on the choice of food especially at the last meal. As you can see from this photo it's a rich plate with dairy products with eggs with cheese with yogurt with milk with beans with fruits and vegetables. What is not there in abundance is bread or rice or potatoes. In general a reduction in carbohydrate and more focus on protein. Why. Because protein would last, if combined with a small amount of fat, longer in the system. When you have a high glycemic or local glycemic carbs it lasts for some hours. But protein and fat will last longer and with less glycemic excursions. So we need obviously to think of the different dietary in different countries. And I'm delighted that we now have on our website the Ramadan nutrition plan with different options and that will be discussed further in the following presentation.

[00:20:25] So it's very important that we individualize the care for the person with diabetes. Assessment before Ramadan for the risk categories for the type of treatment and for the general management plan and then planning that meals, planning the treatment, and the frequency of the self-monitoring of the blood glucose. And then after Ramadan, it's important to assess how good or how bad the care was and have a reflection on this. The self-monitoring of the blood of course is very important and I'm not saying that the person with diabetes should be checking seven times a day. These are the times that are important to keep an eye on over the week. How frequent, depends on the type of diabetes and the type of treatment and all the other circumstances mentioned before. Important to remember checking before sunset and in the late afternoon as this is the peak time for hypoglycemia. Equally, it's important to check during the eating hours to specifically look into post prandial hyperglycemia.

[00:21:36] So understanding that one must break the fast if the blood glucose is below 70 milligrams or three point nine millimoles per liter as well as in sudden excursion of the blood glucose for someone who is well controlled and all of a sudden it exceeds 60 millimoles or 300 milligrams. Certainly when a person has the symptoms of hypo, hyperglycemia or dehydration or any acute illness. That would be important to check on the spot and to break the fast.

[00:22:12] So what can we do with the medication? Metformin is an easy drug for Ramadan. If it's taken once a day, it can be taken at this start. Twice a day then at the two main meals without adjustment of the dose. Three times a day then maybe two tablets at the main meal and one tablet at the pre dawn meal. If the person is on the longer-release, extended release tablet, there is no need to adjust the timing. They can take it at Iftar or at Suhoor. What can we do with regards to other types of medication for example, glitazones. Pioglitazone has one study in Ramadan. We know it as a class of a drug with low risk of hypoglycemia and it showed that in the study as well. There is no need to adjust the dose or the timing; it is once daily tablets What about SUs? There are different types of sulfonylureas that are available, Glibenclamide, Glimepiride, Glipizie, these are the drugs, the sulfonylureas, available across the globe and in general glibenclamide, has been shown to have the highest risk of hypoglycemia during fasting. The others, the more modern ones, have less risk of hypoglycemia and that has been shown in a number of studies. So if you are taking sulfonylurea, it's important to remember that, and indeed to try to adjust the dosing and the timing. Once daily, were advised to take sulfonylurea at Iftar and to reduce the dose if if the control is good. Twice a day, normal dose at Iftar, and half the dose at the pre dawn meal. And As I mentioned it is better to change from glibenclamide to the other more modern second generation sulfonylureas.

[00:24:19] What about DPP-IV inhibitors, when compared to sulfnonylureas? I have been involved in some of these studies and in general the hypoglycemia rate was lower the glycemic control was sustained with the reduction in body weight if it was excessive. Sitagliptin studies have also been done and there were two major studies and it did show, in general, better outcomes compared to the general SU in dark blue. Sitagliptin studies did not look into HBA1C or weight reduction, or weight changed during Ramadan. So in general what we say DPP-IV inhibitors we have two of them that are being tested and they do what we know about them lower risk of hypoglycemia, weight neutrality and they have good efficacy for glycemic control. The other thing before inhibitors have not been tested but I don't expect the outcome to be significantly different of course would love to see these studies. There's no need to change the timing or the dosing of DPP-IV inhibitors during Ramadan. Now SDLT2 inhibitors such as dapagliflozin and canagliflozin have been tested during Ramadan, although are very recent studies. The dapagliflozin study was done in Malaysia and that was a small study in 110 persons, and it showed less risk of hypos with numerically higher risk of thirst but not statistically significant. Of course it's important to remember that we need to exclude those people with renal impairment, those elderly, or those on diuretics. I was the first author on canagliflozin study, which was presented in Diabetes UK conference this year. And the study looked into canagliflozin plus metformin plus minus DPP-IV inhibitors versus sulfonylureas with metformin or a DPP-IV inhibitor. And the hypoglycemia rates were lower in canagliflozin as we can expect. The thirst and the dehydration rates were higher but that did not reflect on the fasting adherence, the total number of fasting days or the ability to take the tablets, only a very small number of people did not take the tablets because of side effects for the thirst or hypoglycemia. So in general, we are saying that SGLT2 inhibitors, although they are quite new, they seemed to be from two studies relatively OK to be taken during Ramadan and no need to restrict. GLP1 receptor agonists, has been tested in three studies. This is the one done called TREAT4 Ramadan done in the UK and it did show less risk of hypoglycemia. The largest study which is called LIRA-Ramadan trial was done in a number of countries and showed similar glycemic control, but the hypoglycemic end points were better for between liraglutide, the GLP1 receptor agonist and the sulfonylurea. So what we say in our guidelines that GLP1 receptor agonists have lower risk of hypoglycemia, while effective in weight reduction and good glycemic control. There is no need to change the dose or the timing. Once a day or twice a day or once weekly, could be given and there is no need to change the dose. There is one important point that there is no need to initiate such a type of treatment very close to Ramadan because of the side effect of nausea, which could be worse during Ramadan. So if you feel that your patient is very in need to have a GLP1 receptor agonists, if the time is too close to Ramadan, then I would postpone it to after Ramadan or advise your patients to break the fast if they have feelings or symptoms of nausea.

[00:28:27] What about insulin therapy? Apart From basal insulin, a person on insulin need to know that they are at high risk and advised not to fast. If they wish to fast that insulin analogs have been shown to be better than human insulins. And obviously we need to check several times a day as well as to adjust the dose. We do not have large randomized controlled trials for many studies in Ramadan but they are starting to emerge over the last few years and one of them was earlier this year. So it's important to remember that if the person is on basal insulin, to advise them to take this insulin at Iftar, at the main meal in the evening, and reduce the dose by 15 to 30 percent. If they are on twice a day, then they would take the usual dose at Iftar and reduce the dose by 30 to 50 percent. Short acting insulin is best to be tailored to the carbohydrate intake. So a bit of carb counting here and for the single dose the early morning dose where the person would be fasting afterwards, it is wise to reduce to dose anyhow. For mixed insulins, we advise that if the once daily dose to take it at Iftar with no reduction in dose. The twice daily mixed insulins is to take the higher dose at Iftar and the smaller dose at Suhoor and reduce it by 25 to 50 percent. Three times a day, obviously to omit the third dose. But in all of the patients with insulin, it is crucial to empower your patients with an algorithm, to test and to modify the insulin dose. If they are within the Ramadan target not to change the insulin dose, if they're lower to reduce by 2 units, if they're higher to increase by 2 units. Obviously if the target is very far from the actual figure, then you can use plus 4 or minus 4. So it's very important that we remember that at the end of the day when it comes to pregnancy, as I mentioned earlier, a pregnant woman has two reasons to be exempt from fasting for this particular Ramadan. The pregnancy itself as well as the diabetes. And that has been reinforced by all the religious authorities. If the pregnant lady has insisted on fasting, then she should be treated as a type 1 person with diabetes. If she is on insulin with all the caveats and requirements for insulin management. If they're on metformin then still we need to monitor for the post-prandial hyperglycemia as well as for hypoglycemia. Now technology could be fantastic and we are now communicating with each other via technology and we still need to use this technology to convey our best indication efforts to our people with diabetes. I'm showing you here a model of technology for patients with diabetes that was done in Egypt as well as in Senegal and it managed to get to so many patients. And the feedback from the patients, as you can see here from this slide was quite supportive, where 100 percent felt that they would be happy to receive information for the following year and to pass the information to friends and relatives and so forth. So it's quite important that we think out of the box and utilize all the options we have. So in summary ladies and gentlemen, Ramadan fasting is a passion for so many Muslims who are 23 percent of the global population. It's important that we look into all the options and the guidelines have tried as much as possible to be practical guidelines. Education is key and internalization of the care is paramount. Many of the modern medications have shown better outcome compared to traditional treatment. However, we do need to have more research into the field.

[00:32:40] Thank you very much Dr. Hassanein, for developing and delivering such a great presentation on explaining the implications of Ramadan among those living with diabetes. Now to present the dietary recommendations for people with diabetes who plan to fast during Ramadan and to share insight from clinical practice, we have Vivian Ng who is a registered dietitian and certified diabetes educator with a Master's of Public Health and Community Nutrition. Vivian works at Don Mills Diabetes Education Program at Flemington Health Center in Toronto. Flemington Health Center is an innovator in creating and running Ramadan and diabetes programs at community health centers and mosques throughout the GTA for more than eight years. Vivian has had the privilege to help contribute to the curriculum and provisions of these programs. In addition to seeing many clients one on one for diabetes and Ramadan counseling. She is a strong advocate for supporting safe fasting whenever possible. So thank you Vivian for joining us and over to you.

[00:33:49] Thank you Stephanie. Thank you for having me here today. So in terms of objectives, I'm going to review kind of the main dietary recommendations for people with diabetes who intend to fast during the month of Ramadan and also share some insights along the way from clinical practice experience in supporting clients to fast safely. So to start I like to compare how meal patterns are different when patients are fasting during Ramadan versus their usual diet as this can help us understand some of the recommendations. So when patients are not fasting their usual nutrition guidelines are to have three regular meals. So usually the breakfast, lunch and the dinner and space no more than about four to six hours apart and also to ensure that they have adequate fluid intake throughout the day. However during Ramadan, things change. Many people might only eat one or two meals a day and they're spaced about 16 hours apart this year. So from sunrise to sunset which is a really long time, and their fluid intake is also limited because you're only drinking during the non fasting hours which is only about eight hours in the night. And oftentimes that intake of sweets and fried foods can be increased as well during this time.

[00:35:30] The first recommendation is to try and distribute total food and caloric intake as evenly as possible over two to three meals and snacks. The primary goal is to avoid very high or very low blood sugars throughout the day. As mentioned earlier the total non fasting period is only about eight or nine hours and you're trying to fit two or three meals in during this short period of time. The recommendation is to have the Suhoor, which is the early morning meal before sunrise, ao around 5:00a.m. or so, then Iftar around 9:00p.m. and then another small snack or meal a few hours later to help get enough nutrients and calories in. In terms of caloric distribution, you want to try and have about 30 to 40 percent of calories at the morning meal and about 40 to 50 percent with the evening meal and then the rest 10 to 20 percent with the third meal or snack in the night. Basically you're trying to mimic a usual meal pattern as best as possible.

[00:36:46] The second recommendation is actually to encourage patients to wake up for Suhoor and not to skip it. You might find that some people skip suhoor or eat very little. Like some people might just eat a banana or something really small. It's understandable because it's quite early in the morning and they might not have had very much sleep the night before, but it's really important to encourage them to try and wake up and eat as much as they can especially those who are working or have more active lifestyles, it can really help to prevent hypoglycemia and also to help maintain energy levels throughout the day. You also want to encourage them to have suhoor as late as possible meaning as close to sunrise as possible to help it last throughout the day. By eating this morning meal, it helps to avoid them just eating one large Iftar in the evening when the fast is broken. Because that will result in very high post prandial blood sugars. So for Suhoor, you want to aim for a balanced breakfast with a few different food groups. So in terms of carbohydrates you want a bit of carbohydrates that are whole grain and low glycemic index. Because this can help to prolong satiety and reduce hypo as well as hyperglycemia. In addition to that, you want a source of protein and healthy unsaturated fat, as both of these things helps to increase and prolong satiety in the day. So some examples I often recommend to patients are let's say some whole wheat chapati with lentils or whole grain bread with some eggs, avocado or oatmeal or porridge with some fruit some nuts in it things like that. Lastly for suhoor, you want to encourage patients to drink as much water as they can before starting to fast, to help prevent dehydration in the day. You want to encourage them to limit coffee or very strong teas as they're diuretics obviously and can increase dehydration instead of hydrating them before starting to fast. At sunset the tradition is to break the fast with dates. I don't usually recommend that patients with diabetes eat dates on a regular basis because of the sugar content. However during Ramadan dates are a very important part of breaking the fast from a cultural perspective for the patient. So I think it's really important to respect that. And so I usually recommend that patients limit to one or two dates. And along with dates you want to encourage patients to rehydrate immediately so usually with water or plain milk and continue to do so throughout the evening. It's important to limit juices or other sweetened beverages because it can lead to very high blood sugar, especially if they're just about to eat a large meal.

[00:39:59] After the fast is broken, you would normally have iftar, the evening meal, so you can recommend that patients use the traditional plate method which has the half plate vegetables the quarter starch and the quarter protein food. Or the Ramadan plate, as you can see here it's fairly similar but a bit more calorie dense to help get enough nutrients in and it's a bit more culturally adapted. You can individualize the plate based on the patient's food preferences and caloric needs but the goal is to try and eat a variety of food groups to get all of the required nutrients. As always you want to encourage low glycemic index and whole grain carbohydrates to help manage those post prandial blood sugars. Lots of vegetables, beans and lentils are really good too, yogurt, dairy products altogether for a balanced meal. Generally I encourage patients to use fruit as their dessert at the end of the meal. So both at the morning and the evening meals and sometimes as their snack in between as well. If possible, I always try to involve the family and whoever is the cook when discussing food choices and planning for Ramadan because this can be very helpful to have the family support and cooking foods that fit into the different food groups and kind of fit on the plate method. You can also work out a plan together to make some of the fried foods or sweet foods less often during the month of Ramadan.

[00:41:41] Some other things you might want to think about in terms of diet. I mentioned limiting caffeine and so caffeine withdrawal and headaches can be quite common especially if patients are normally drinking several cups of coffee throughout the day and then all of a sudden they're drinking significantly less during Ramadan. So I try to remind them to start gradually reducing their intake before the start of Ramadan to help minimize some of those withdrawal symptoms. Constipation is also something to watch for, as during Ramadan there's a drastic change in eating patterns, changes in water and fluid intake, as well as activity levels. Changes in bowel routines can also happen because the patient changes their caffeine intake because it's a bowel stimulant. Oftentimes patient can also experience indigestion or heartburn more during Ramadan. If they're eating more high fat foods or fried foods than usual or if they're having very large meals, or if they're sleeping right after eating a large meal. Some other general tips if you're doing Ramadan education. It really helps to start the discussion about Ramadan early so that you can make a plan together kind of about food or medication especially if changes are necessary in their meds or their insulin. I try to make a note in the patient's chart or in my own chart notes to kind of try to remember to talk about it at the next visit if Ramadan is coming up.

[00:43:27] My next step is geared more towards community based clinicians. I'm fortunate to be working at a community health center where I have the support of an outreach worker on my team. So for a lot of our Ramadan programming she does outreach at local mosques and places of worship in the community to reach those with diabetes who plan to fast. What we usually do is we do a group education sessions at the mosques and after the group session participants are welcome to kind of make a follow up appointment to discuss further or discuss their individual situation. In doing this type of outreach a key part of it is to develop the relationships with religious leaders so that they can also encourage those with diabetes to both either attend the group sessions or to make the initiative and discuss it with their diabetes team or their doctor to assess whether it's safe for them to fast. So if you do work in the community and have the capacity to do this type of outreach I would really encourage your team to do that. As we have really found it to be quite effective and quite well received.

[00:44:40] And I just wanted to share some of the resources with you. Dr. Hassanein has already mentioned the guidelines, the IDF and the DAR guidelines. I also found them to be really really helpful and useful so I would encourage you to check those out. In terms of the food part of things on the web site, there are what they call the Ramadan and nutrition plans on there which are very detailed sample meal plans that are culturally adapted to several different countries. So if you wanted a kind of sample meal plans they're kind of all on there. They have different caloric targets for both males and females. And then other web sites that have some Romney on and diabetes information are the Diabetes UK as well as the ADA Web sites have some information about that as well.

[00:45:41] Thank you very much Vivian for your insightful overview of the dietary components and clinical insight regarding fasting during Ramadan and diabetes. So now it's time for our Question Period. For those of you who have questions and haven't done so please type your questions into the question pod to the right of your screen. Please note for all questions that we aren't able to answer today please send us an email at professional.membership@diabetes.ca and we will get back to you as soon as possible. There were some questions addressed during the presentation. So we have one guest ask: Thank you for the presentation. My question is geared towards this specific population bariatric patient. Are you aware of evidence and practical guidelines for Ramadan fasting after bariatric surgery? Thank you for this question. It's a fascinating one because obviously we do not have lots of evidence in general and obviously bariatric surgery is an area with an increased use. Some people after bariatric surgery would have a bit of GI side effects such as nausea or hypoglycemia post high sugar meals and the dumping syndrome. So obviously for them, fasting might be difficult in case their nausea level is higher or in case they suddenly have a high surge of calories intake specifically the high sugar calories. So it varies from person to person if a person post bariatric surgery have any of these side effects they might like to avoid fasting but otherwise if they're able to fast then maybe they wouldn't be able to do so. So I'm afraid it's a bit of trial and error.

[00:47:49] Thank you for that answer. Hopefully that provides a sufficient answer for that person. So we have lots of questions coming in so I will try to address them as best as we can. I bet again we will e-mail our questions afterwards and we'll reach out to you.

[00:48:27] So there's a question about insulin. One of the attendees did send a question about a child with Type 1 diabetes who is not going to be fasting but the rest of the family will be fasting. So the option for this person obviously is to join in the festivities at the main meal time, eating time would be in the evening if they need to have lunch they can have lunch when they go home. And obviously will follow the same regulations. As for another of the same person ask about intermediate type of insulin. We have addressed this in the guidelines so intermediate type of insulin such as NPH, if they're once daily that we are advised to take that at the main meal time if they’re are twice daily to take the second injection at the earliest hours of the morning with the suhoor but to reduce the dose by up to 50 percent. We're giving them an algorithm to dose titrate, then hopefully they will be able to adjust the dose up or down based on their own individual response.

[00:49:44] What Is the most acceptable way to treat a low during Ramadan? Well the hypoglycemia a low blood glucose level need to be treated on the spot and we advise people that they really need to respond to hypoglycemia as quick as possible and swift as possible. Some would be resistant to do so especially if they have fasted for many hours and the low blood glucose level is happening close to the time when they're about to complete the fast for the day. Having said that in normal practice if I now have hypoglycemia I don't think anyone will say to me wait for another 30 minutes until we have a break. You will be offering me something sweet or sugary now. So it's important to apply the same rules during Ramadan as well.

[00:50:43] Suhoor ends around two hours before sunrise. Is this something we said we need to consult with our religious leaders? Some people mix between sunrise and the timing of break at the beginning the fast which is dawn. Dawn is the time of the beginning of the fast and this is not sunrise. The gap between dawn and sunrise varies from place to place and a country to country. There is no person who can change that tribulation because it's part of the simple Ramadan recommendations. Now we need to know the timing of the beginning of the fast and ending of the fast and if the time is too short it certainly would add to the burden that the person would need to consider when they make their decision of fasting or not.

[00:51:40] How would you advice a patient with GDM who insists on doing the Ramadan? Thank you for this question because it's a frequent problem that many people consider gestational diabetes as possibly no diabetes or simple measure. They consider that the risk of hypoglycemia to be quite low. Maybe the risk of hypoglycemia could be low, however studies are ongoing to assess this more thoroughly. But the main power to target during pregnancy is to avoid post prandial peaks, when you see a pregnant lady of Ramadan, you are advising the lady to have frequent small meals and that the post prandial glucose to be below 120 milligrams which is the equivalent of I think 7 millimoles two hours after a meal. So if someone is fasting for 17 hours can really have a small meal afterwards and they postprandial glucose is lower than this then they are the minority because the majority would have difficulty to do so. Let alone spreading of the total calorie intake for the day within the eight hours that they are allowed to eat as well as the fluid intake and at the end of the day the woman is not going to be fasting and will be pregnant for the future months. If they insisted on doing so then frequent monitoring and applying the same regulations during out of Ramadan days of avoiding hypos and avoiding post prandial peaks would apply with the nutritional advice on the type of food and the quantity and the frequency of it as well.

[00:53:27] We've had a couple of questions about exercise. So what would be the best type of exercise to engage in during Ramadan? And what is the best time or flat duration? Thank you again for this important point. We have hinted to it during our presentation. The highest risk of hypoglycemia it is during the last few hours before the fasting is complete which is late afternoon until sunset. The rest of the time I would avoid having strenuous exercise or moderate level of exercise. So if I would like to exercise, going to the gym or walking or doing any types of sports it's best to be done in the evening where you can eat and replenish your fluid intake. During the normal working hours, low level of exercise would be OK. Taking into consideration of course the type of treatment of the type of glucose control of the person and whether they are on any other diuretics or so forth.

[00:54:36] How do you counsel a patient with type 2 diabetes who decides to skip medication during Ramadan because they feel that they are not eating much anyways? This is a common practice that many people would do. As you can see from our guidelines we have recommended reducing insulin dose, we have recommended reducing sulfonylureas dos at the time of fasting hours. So the support treatment would be reduced in an amount but omitting it altogether would need the self-monitoring of the blood glucose to confirm that this is the case. Let's not forget that the best way to counsel a person is your fasting to fulfill the obligations in the person's own religion and the religion certainly does not advocate harm to the body. So if you're if the person's action can lead to harm that is something that you can press upon that these recommendation are agreed by experts in the field from medical and from religious aspects. So avoiding harm is quite important. If because of their lifestyle they need no medication during the daytime. And that's proven by the blood glucose levels then by all means no problems. But if that leads to hyperglycemia then they certainly need to reconsider the dose of the treatment or indeed fasting altogether.

[00:56:04] So I think this is about our last question. But why do you encourage clients to drink water as much as possible before fasting? I Thought they were still able to drink fluids when non fasting? Let me explain again what this fasting Ramadan means. Fasting Ramadan means no food no drink no tablets no smoking at all between the hours of fasting and non fasting. So obviously maybe the person asking the question thought that they are allowed to have fluids while they're fasting and that's not the case. The time of eating and drinking starts from sunset to dawn.

[00:56:52] I wanted to thank everyone who has been on this call. Dr. Hassanein. Thank you very much for your tremendous knowledge. Vivian, thank you for presenting your perspective on it. We very much appreciate it. And of course you've been a tremendous part of the Diabetes Canada family over the years and we thank you for that. We will be getting the emails and with the answers to the questions out. If You wish to review this seminar or have a colleague look at it will be posted on to our web site. So once again thank you everyone. Thank you Stephanie. Thank you Mohammed and thank you Vivian. I wish you all the very best. Take care.