With Karl Nadolsky, DO and Jonathan Gabison, MD
For many Muslims, the ability to fast during the holy month of Ramadan is vital to their spiritual well-being. But for those with diabetes, fasting from food, water, and medications – even for part of day – can be dangerous. However, in a new study released in March, researchers found that many can, indeed, participate in this important rite without significant danger and potentially could improve A(1)c levels.
In the study, 97 patients were randomized into two groups, one that used an algorithm to determine how best to support patients through their fasting, and one that did not have that intervention. All had type 2 diabetes and intended to fast over the two Ramadan periods studied. Providers and patients alike were invited to a pre-Ramadan educational seminar, although only those in the intervention group were given educational materials.
That group and their physicians used the FAST algorithm to determine how to ensure patients could safely fast. The study included a support line available for patients during the month of Ramadan and instructions to test blood glucose at least four times daily during the month. After Ramadan ended, patients reverted to their usual care.
Clinical Outcomes
The desired clinical outcomes were based on A(1)c levels, fasting, post-prandial glucose levels, and glycemic variability. Safety outcomes measured were any hypoglycemia events during Ramadan. Lastly, they measured diabetes distress using a proven questionnaire.
Those in the intervention group had significantly better A(1)c levels, decreasing 0.4%, four times the decrease in the control group. The numbers reverted back to previous levels a month later. However, fasting blood glucose in the intervention group declined, and stayed lower after three months. It increased in the control group – both during Ramadan and further in the three months following – beyond recommended target levels. Post-prandial glucose was not statistically different between the two groups, nor was glycemic variability. Neither group had any reported hypoglycemic events. Both groups reported decreases in diabetic distress, both during and after Ramadan.
Analysis and discussion
This was the first attempt to formally evaluate the FAST algorithm, says Joyce Lee, Pharm.D, a clinical professor in health sciences at the University of California, Irvine and one of the study authors. “Positive clinical and humanistic outcomes from this research suggested a potential for adopting the collaborative algorithm into practice, especially for Muslim-minority countries,” she said. “We hope that this study will bring more awareness and confidence to healthcare professionals who encounter patients with type 2 diabetes who wish to observe Ramadan.”
While there are other faiths that have fast days – Yom Kippur for Jews, for instance – Lee said you can’t extrapolate using this kind of tool to another kind of fast. “However, the elements of patient/provider empowerment and collaborative care approaches from the algorithm can be applied universally to ensure effective and safe fasting. The fact is, everyone is different, and the key is to provide individualized care. For example, an effective fasting duration for one person may result in weight gain or hypoglycemia in another.”
"The outcome of longer term fasting patterns remains unknown, and would depend on comorbidities, medical history, activity level, and medication history," said Lee. “At the end of the day, what is most important is for patients and providers to work together, with open communication and trust, to come up with an individualized plan that meets the patient's needs.”
She said, "I'm excited about the possibility to transform the management of diabetes during Ramadan for fasting Muslims. Our work found that healthcare provider empowerment in a form of structured guidance for individualized care, and patient empowerment in a form of self-titration of medications using self-monitoring of blood glucose, brought about greater improvement in clinical outcomes without imposing additional distress to the patients. In addition, the collaborative nature of our algorithm also promoted safer fasting.”
There will always be some patients for whom fasting is just too dangerous, said Karl Nadolsky, DO, an assistant professor of medicine at Michigan State University. For some, prolonged fasting can actually be a benefit – those who have adiposity-based type 2 diabetes, treated with diet and medications, for instance. But “it is dangerous to some degree to risk dehydration from avoiding fluids while fasting, which may make medications such as SGLT2 inhibitors riskier.”
Those with type 1 diabetes face a trickier decision, depending on the patient’s mode of insulin delivery and accuracy of the daily required insulin dosing calculation, he said. “Hypoglycemia is the obvious primary concern during a fast if fasting or basal insulin is not optimal. It is certainly influenced by delivery via long-acting insulin analogue or differing basal rates for continuous subcutaneous insulin infusion. The progress of continuous glucose monitors and now hybrid closed-loop systems provides a great advancement for these patients and should provide a much safer ability to mitigate the risks of Ramadan fasting.”
He added that hyperglycemia and diabetic ketoacidosis have also been reportedly increased in those with type 1 diabetes before and during Ramadan, making it critical to get carbohydrate counting and correct dosing calculations as close to optimal as possible in preparation.
Like Lee, Nadolsky said that fasting for a whole day, as is the case for some Jewish holidays, is a potentially higher risk activity, but it depends on the type of diabetes and therapy used. “While a longer fast may actually benefit a person with type 2 diabetes if staying hydrated and keeping the dietary intake otherwise optimal, it could be very risky for somebody with poorly controlled type 1 diabetes on a suboptimally calculated insulin regimen who does not do as well with hydration and dietary quality.”
Sleep is also critical to consider in any kind of fasting, Nadolsky noted. “Patients may alter their sleep habits to help facilitate and tolerate the fasting which can alter glucose tolerance physiology and may help or hinder their efforts.”
Nadolsky said that for patients who have type 2 diabetes and are obese, intermittent fasting may be a way to improve both weight and glycemic control. But high risk patients, like those with poorly controlled type 1 diabetes, the eldery, or those with complicated comorbidities are probably best served by discouraging a fast. “If adamant, then we would take all the precautions possible, including close follow up with diabetes educators/dieticians, continuous glucose monitoring, insulin dosing adjustments, and low threshold to break the fasts."
The beauty of the protocol used by Lee and her colleagues is that it takes an evidence-based approach, said Jonathan Gabison, MD, a physician in the department of family medicine at the University of Michigan who wrote an editorial accompanying the study. “The protocol evolves based on the patient's response to fasting and with the diet they are consuming.”
Gabison said that full-day fasts, and those that don’t include water, can be dangerous and lead to severe side effects, but if a patient wanted to engage for spiritual reasons, “I would definitely discuss these risks with the individual patient and try to better understand the spiritual value of the fast to see how I can best support them. Can the FAST protocol be used to help guide a physician and a patient? Yes, but the beauty of the protocol is how to change the medications over time, and that wouldn’t happen with a one day fast.”
Conclusion
For intermittent fasting, this tool can be a real help to physicians and patients. “Fasting is not for everybody, but it can be another tool we use to combat chronic diseases, like obesity, metabolic syndrome, and type 2 diabetes. There is a growing body of evidence that intermittent fasting has health benefits for people who are able to stick to a regular regime. This protocol gives physicians a tool we can use to support our patients, even with co-morbidities, in making this lifestyle choice.”
