International Journal of Diabetes Mellitus
Volume 2, Issue 2 , Pages 127-129, August 2010

Effects of Ramadan fasting on children with Type 1 diabetes

  • Ibrahim AlAlwan

      Affiliations

    • College of Medicine, King Saud bin Abdulaziz University for Health Sciences, Saudi Arabia
    • Pediatric Endocrinology Division, King Abdulaziz Medical City-Riyadh, Saudi Arabia
    • Corresponding Author InformationCorresponding author. Address: College of Medicine, King Saud bin Abdulaziz University for Health Sciences P.O. Box 22490, Riyadh 11426, Saudi Arabia. Tel.: +966 1 2520088x47116; fax: +966 1 2520088x47113.
    • ,
  • Abdulhameed Al Banyan

      Affiliations

    • Pediatric Endocrinology Division, King Abdulaziz Medical City-Riyadh, Saudi Arabia

Received 17 March 2010; received in revised form 10 May 2010; accepted 16 May 2010. published online 10 June 2010.

Article Outline

Abstract 

Some children with diabetes, despite their exemption, insist on fasting in Ramadan. We evaluated the safety of fasting among children with Type-1 diabetes.

Methods

During Ramadan 2007, 20 children with Type-I diabetes were recruited and divided into two groups. Short term diabetes complications were recorded. Changes in weight, HbA1C and lipid profile before and after Ramadan were compared.

Results

Fasting group (n=12, mean age 12.4years). Non-fasting group (n=8, mean age 10.5years) showed no significant difference in HbA1c (P=0.9), weight (P=0.96) or fasting lipid profiles.

Conclusion

Supervised fasting with close observation may be safe with no short-term parameter changes.

Keywords: Type 1 diabetes mellitus, Ramadan fasting, Children, Riyadh, Saudi Arabia

 

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1. Introduction 

Adult Muslims are obliged to start fasting during the month of Ramadan. Fasting entails refraining from all food, drink, tablets and injections between sunrise and sunset; a period which varies by geographical location and season. Children, elderly people, travelers, pregnant or nursing women and unhealthy individuals are exempt from fasting [1]. Although exempt, many diabetics, both adults and children, refuse to take this concession as they feel psychologically and spiritually inclined to fast along with other Muslims.

Ramadan fasting may directly influence the control of diabetes because of the month-long changes in meal times, types of foods, use of medication and daily lifestyle [2]. During fasting eating and drinking is exclusively nocturnal. A fasting person typically takes two meals: a large, high caloric meal after sunset (Iftar) and a small, low calorie meal just before sunrise (Sahor). Small snacks may be taken between these two main meals. Meals are usually high in carbohydrates and fat content [3]. Many may fast without medical guidance, and may develop complications [4], [5], [6], [7].

In spite of the observation that many children and adolescents with diabetes do fast during Ramadan particularly in Muslim countries, little is known about the safety or metabolic effects of fasting in children with diabetes.

The aim of this study is to look into the safety and metabolic consequences of Ramadan fasting among children with Type I diabetes mellitus (T 1DM).

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2. Methods 

This prospective case control study was conducted at the King Abdulaziz Medical City, Riyadh, Saudi Arabia during Ramadan 1428 (September 13–October 12, 2007). Patients were recruited 3months before the start of Ramadan, according to the following criteria:

We included children aged between 8 and 14years who had Type 1 diabetes mellitus for more than one year, who agreed and consented to participate in the study. Patients with no recurrent hypoglycemia, or long term diabetes mellitus related complications, were excluded.

Outcome measures included number of hypoglycemic episodes or DKA during fasting, Changes in HbA1C, and lipid profile (cholesterol, triglycerides, LDL and HDL) after fasting and weight and BMI pre and post Ramadan.

2.1. Study protocol 

Patients were divided into two groups, based on whether they chose to fast. Those who elected not to fast during Ramadan were considered as the ‘non-fasting group’, and were used as the control group, whereas patients who had chosen to fast were considered as the ‘fasting group’. Patients in the fasting group who experienced hypoglycemia were instructed to break their fast. Patients who withdrew from the study were not replaced. During non-fasting periods, the patients were allowed to have their usual food, based on physician’s advice. All patients were seen in the clinic weekly during Ramadan. Weight, height and BMI were recorded, and blood samples were collected on the first and last day of Ramadan. All patients were provided with a 24h help line, and asked to record their home blood glucose regularly and any hypoglycemia episodes. Evidence of DKA admissions were taken from hospital records.

During the three months prior to Ramadan, patients in the fasting group were given intensive education and written instructions provided by diabetic educators, dieticians and physicians on insulin adjustment, home glucose monitoring, dietary adjustments and activity changes during Ramadan.

2.2. Insulin adjustment 

All patients were on multiple daily insulin injections (MDI), and their written instructions to insulin adjustment were as follows:

•Pre-Iftar dose equal to pre-Ramadan lunch dose of rapid acting insulin.

•Pre-Sahor dose equal to pre-Ramadan evening dose of rapid acting insulin.

•Pre-Ramadan Basal dose was reduced by 20% and given in the evening.

Home glucose was monitored pre-Iftar, 3h post-Iftar, pre-Sahor and any time during the day when there was a risk of hypoglycemia. If glucose was higher than normal, patients were instructed to give a corrective dose of one unit of fast acting insulin for each 50mg above the normal range.

2.3. Biochemical analysis 

All patients had blood samples two days prior to, and on the 29th of Ramadan after a minimum of 12h overnight fast. Blood glucose, glycosylated hemoglobin (HbA1c) was measured by High Performance Liquid Chromatography (HPLC) analyzer: Variant II Company Bio-rad, USA, total cholesterol, triglycerides, low density lipoprotein (LDL) and high density lipoprotein (HDL).

2.4. Statistical analysis 

Analysis of significant metabolic changes pre- and post-Ramadan was assessed by P value based on analysis by SPSS program Version 12. Data were expressed in mean±standard deviation (SD). Wilcoxon Signed Ranks test was used to ascertain the significance of the difference between mean values. The P value <0.05 was considered to be the cut off value of significance.

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3. Results 

During Ramadan 2007, the average fasting period in Riyadh city was 12½h per day, starting at 5AM (dawn) and ending at 5:30PM (sunset).

A total of 20 patients agreed to take part in the study. Twelve children were in the fasting group, and 8children in the non-fasting group. Only one child, in the fasting group, withdrew from the study, due to hypoglycemia experienced on the second day of Ramadan, 3h after the Sahor meal. The fasting group was older, with mean age of 12.1years (SD±1.1) as compared to non-fasting group mean age was 10.6years (SD±1.9). Female participants were slightly higher than male, with 58% in the fasting group and 63% in the non-fasting group. Across the groups, the duration of diabetes was 2–5years; the fasting group mean was 2years, and the non-fasting group mean was 3years. The mean hemoglobin A1c, for the non-fasting group, 6months before Ramadan was 9.2% (±1.13) and 6months after Ramadan was 9.4% (±1.34) and for the fasting group was 9.13% and 10%, respectively. At the beginning of Ramadan, the weight of the fasting group was heavier than the non-fasting group, with a mean of 42.2kg (±9.6) compared to the non-fasting group, with a mean of 36.6kg (±7.4). In both groups, diabetes control was poor with hemoglobin A1c (HbA1c) just before Ramadan with a mean of 10.4 (±2.17%) in the fasting group and 10.6 (±1.4%) in the non-fasting group. The normal reference in our laboratory, non-diabetic range is 4.4–6.4%.

No patient called the 24h help line and none had either inter-current illness or ketosis.

Changes in hemoglobin A1c, weight and lipid profiles, before and at the end of Ramadan between and among the fasting and non-fasting groups, showed no significant statistical difference, as illustrated in Table 1, Table 2.

Table 1. Comparing weight, HbA1c and lipid profile before and at the end of Ramadan among fasting and non-fasting groups.
ParametersPatient groupsBefore RamadanEnd of RamadanDifference P value
Weight (kg)Fasting42.2 (±9.6)42.6 (±9.4)0.152
Non fasting36.6 (±7.4)37.1 (±7.68)0.345
Hb1Ac⁎ (%)Fasting10.4 (±2.17)10.4 (±2.07)1.000
Non fasting10.6 (±1.4)10.4 (±1.2)0.483
Total cholesterol (mmol/L)Fasting4.3 (±0.4)4.4 (±0.3)0.445
Non fasting4.4 (±0.3)4.5 (±0.5)0.944
Triglyceride (mmol/L)Fasting0.62 (±0.15)0.62 (±0.17)0.514
Non fasting0.6 (±0.2)0.6 (±0.2)0.674
LDL (mmol/L)Fasting2.6 (±0.3)2.7 (±0.3)0.333
Non fasting2.6 (±0.3)2.3 (±0.9)0.499
HDL (mmol/L)Fasting1.48 (±0.23)1.42 (±0.13)0.445
Non fasting1.5 (±0.3)1.6 (±0.3)0.674

LDL: low density lipoprotein cholesterol; HDL: high density lipoprotein cholesterol.

⁎Normal non-diabetic range 4.2–6.4%.

Table 2. Comparing the change in weight, HbA1c and lipid profile before and at the end of Ramadan between fasting and non-fasting groups.
Parameters of meanDifferences before and at the end of Ramadan non fastingDifferences before and at the end of Ramadan fastingDifference P value
Weight (kg)0.39 (±.96)0.37 (±.76)0.968
Hb1Ac (%)−0.14 (±1.0)0.00 (±1.05)0.904
Total cholesterol (mmol/L)0.49 (±0.48)0.13 (±0.57)0.573
Triglyceride (mmol/L)0.04 (±0.17)0.03 (±0.14)0.829
LDL (mmol/L)−0.23 (0.85)0.16 (0.48)0.408
HDL (mmol/L)0.02 (±0.28)−0.07 (±0.19)0.360

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4. Discussion 

Current evidence has proved that with proper education, appropriate adjustment of the drug regimen, diet control and daily activity, it is safe for adult diabetics with Type 1 and Type 2 to fast during Ramadan [1], [4], [5], [8], [9], [10], [11], [12].

Diabetics usually insist on fasting, often without the approval of their physicians. This insistence may be a reaction against the feeling that due to their disease, they are physiologically different from other members of the community [13] or from the fact that Ramadan fasting is one of five pillars of Islam and is regarded by all Muslims as an important facet of the practice of Islam. This phenomenon has been documented in a population-based study (EPIDIAR) conducted across 13 countries. This international study revealed adult diabetic Muslims who chose to fast were 78.7% and 42.8% in Type 2 and Type 1 diabetes, respectively. Saudi Arabia was found to be the highest, with 71.6% of Type 1 diabetics choosing to fast [4]. Patel found that 99.1% of Type 2 diabetics opted to fast at one center in Oman [5].

The management of children with diabetes who choose to fast during Ramadan is a challenge for pediatrician as the majority of guidelines and data on safety and metabolic impact of fasting are based on practice and studies on adult population.

All of our patients completed the full month of fasting except one, who had hypoglycemia, and none had DKA. Therefore, our study showed that it is safe for diabetic children under the age of 14years to fast, provided that a well structured program of education for both children and their families is completed prior to Ramadan, and that they receive close follow up during the month of Ramadan.

Data on the effects and safety of Ramadan fasting in healthy and diabetic adolescents are sparse. An earlier study [6] done in the same city on children with similar age group reported three children with biochemical hypoglycemia within the first week of fasting. These episodes contributed to the mis-adjustment of the insulin dose. More recently, another report [7] looking into the impact of fasting among adolescents with T 1DM treated with insulin pump versus conventional insulin therapy identified hypoglycemia of glucose below 60mg/dl on an average of 16–29 readings per month in insulin pump and conventional therapy groups, respectively. However patients in the latter study were older, compared to ours (15–19years), and had better HbA1c with an average of 7.8 and 9.1 for insulin pump and conventional therapy, respectively. We suspect that parental supervision, insulin adjustment and intensive education & follow up are the main reasons for lower hypoglycemia episodes in our patients. It is also possible that high food intake and higher HbA1c in our patients provided them with protection against hypoglycemia.

None of our patients showed significant difference in their fasting lipid profile pre- or at the end of Ramadan, compared to an adult study by Akangi which showed beneficial changes in serum HDL and LDL in normal adults fasting in Ramadan [14].

Our study had some limitations because of the small number of patients with Type I diabetes, and it involved only one center in Riyadh. In spite of these two limitations, the study demonstrates that children over the age of 8years old who are well controlled, educated before Ramadan, have their insulin adjusted and are followed closely in the clinic will show no biochemical short term complications and be able to successfully complete fasting during the month of Ramadan.

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5. Conclusion 

It is feasible for children older than 8years with long-standing T 1DM to safely fast during Ramadan, if the child and family received proper education and intensive follow up clinic during Ramadan. It appears that Ramadan fasting has no significant effect on diabetes control or lipid profile; however further studies are recommended to include a larger sample size with other age groups.

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Conflict of interest statement 

None declared.

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References 

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PII: S1877-5934(10)00031-7

doi:10.1016/j.ijdm.2010.05.009

International Journal of Diabetes Mellitus
Volume 2, Issue 2 , Pages 127-129, August 2010

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