Background
Islamic law exempts patients with poor health from fasting during
Ramadan. Some of our patients with type 1 diabetes are eager for
Ramadan fasting against medical advice and religious exemption.
Current recommendations stratify this subgroup of patients as high
risk for fasting though the published data is sparsely available in
this regard.

Aim
The primary objective is to assess the safety of Ramadan fasting in
patients with type 1 diabetes by monitoring the rate and severity of
hypoglycemia and hyperglycemia during the fasting period and compare
it with the non-fasting state.

The secondary endpoint is to follow the effect of fasting on their
weight, blood pressure, and HbA1c by observing these parameters pre
and post Ramadan.

Method
Patients with a known diagnosis of type 1 diabetes mellitus attending
the Adult Endocrinology Clinic at Dubai Hospital were selected at
convenience 1-2 months before Ramadan, counselled, and asked to sign
an informed consent. Patients with concurrent renal disease or any
recent hospitalisation in the last 3 months were excluded. All the
patients received a 90 minutes session for Ramadan-focused education.
The Freestyle Libre flash sensor insertion was done for continuous
glucose monitoring. Their biophysical and biochemical profile was
collected 2 to 4 weeks before and after Ramadan. We recorded diabetes
related emergency visits or hospitalisation, change in BMI, systolic
and diastolic BP, lipids profile, renal function, HBA1c, and frequency
of hypoglycemia during Ramadan fasting and non-fasting period.

All the quantitative values are described as mean, and analysis of CGM
data is shown in frequencies.

Results and Discussion
A total of 30 patients with type 1 diabetes were recruited, 4 patients
dropped out, 1 of which was due to a hospitalization with diabetic
ketoacidosis. 4 other patients did not complete the full protocol as
they only had one sensor. There were 26 patients in total with CGM
data available. 53% were male and 47% female with a mean age of 23.3
yrs ±7.85. The average duration of diabetes was 8.6 years. The
majority of patients were on basal bolus insulin with the exception of
2 who were on an insulin pump. 21% reported fasting the entire month
of Ramadan with 24 days being the average number of days fasted.

A total of 258 days of non-fasting data was recorded (47%) and 289
days of fasting data in Ramadan (53%). 46.7% of patients had frequent
hypoglycemic events of >10 episodes in 2 weeks during the non-fasting
period compared to 29.2% who had a similar frequency of hypoglycemia
(HE) during Ramadan. There was no difference between the percentage of
patients who had 2-9 episodes of hypoglycemia with 50% of patients in
both groups. More patients had no HE recorded at all on CGM in the
Ramadan group (12.5%) compared to the non fasting period (8.3%). 79%
of patients had a glucose reading below 49 mg/dl in the non-fasting
period compared to 66.7% during Ramadan. The average duration of HE
was slightly longer during Ramadan with a mean of 98.50 minutes ±62.55
compared to 96.33 minutes ±49.32 in the non-fasting period. Most HE
occurred between 00:00-06:00 (average 2.57 per/day) and the least HE
occurred between 06:00-12:00 (average 1.78 per/day) in the non-fasting
period. During Ramadan, most HE occurred between 00:00-06:00 (average
2.08 per/day) and the least events occurred between 12:00-18:00
(average 1.29 per/day). 62% of patients improved in Ramadan by having
less HE, 9.5% remained the same, and 33.3% had more frequent HE during
Ramadan. The mean average glucose around Iftar time was 181.1 mg/dl
±58 and the mean glucose 2 hours later was 231.0 mg/dl ±66.

The average lab HbA1c pre Ramadan was 8.23% and 7.89% post Ramadan.
Pre-Ramadan weight was 70.16 kg ± 17.92 and 69.61 kg ± 16.70
post-Ramadan. Systolic blood pressure was 116.31 mmHg ± 15.45 before
Ramadan and 116.13 mmHg ± 12.25 post-Ramadan. Diastolic blood pressure
was 69.7 mmHg ± 7.46 before Ramadan and 66.31 mmHg ± 10.1
post-Ramadan.

Conclusion
Optimum care for type 1 diabetes resulted in favorable glycemic
control after Ramadan fasting with less hypoglycemic episodes during
Ramadan compared to non-fasting days. Biometric and biochemical data
remained the same, with a minor trend of improvement and there was a
negligible hospitalization rate. Replication of the study in a larger
cohort is essential before clinical application.

Impact of optimum diabetes care on the safety of fasting in Ramadan in adult patients with type 1 diabetes mellitus