Many of those who celebrate the month of Ramadan, which began on April 23 this year, are unable to share this holiday's traditions with loved ones due to the COVID-19 pandemic. Although Muslims are unable to celebrate the iftar (the meal breaking the day's fast after sunset prayers) with those outside of their immediate family due to social distancing recommendations, the importance of fasting during the month of Ramadan has not changed. Fasting is expected of all adult Muslims from sunrise until sunset during the 30 days of Ramadan, excepting those who would endanger their health from doing so. Muslim persons with type 2 diabetes often still wish to fast despite the risks of hypo- and/or hyperglycemia, and a recent randomized controlled trial (RCT) from Singapore suggests those with decent baseline glycemic control can safely participate in fasting.
The RCT, published in the current issue of the Annals of Family Medicine with an accompanying editorial, studied FAST, a new clinical tool:
To address the need for a culturally tailored standard for diabetes care during the month of Ramadan, a multidisciplinary team of clinicians gathered to design an empowerment-based collaborative clinical tool called the Fasting Algorithm for Singaporeans with Type 2 Diabetes (FAST). It is a stepwise clinical decision-making tool with risk-assessment screening, Ramadan-specific patient education with self-monitoring of blood glucose (SMBG), structured glucose-lowering medication modification guidance for health care clinicians, and novel self-dose adjustment guidance based on SMBG readings during Ramadan.The researchers randomized 97 patients with type 2 diabetes who planned to observe fasting during the month of Ramadan into an intervention group (using the FAST tool) or a placebo group (usual care). Participants were excluded if their baseline hemoglobin A1c was greater than 9.5%. Study groups were further stratified into patients using and not using insulin. Intervention group participants had improved fasting blood sugars (-3.6 mg/dL vs +20.9 mg/dL in the control group for a difference of 24.5 mg/dL [95% confidence interval 11.3-37.7]) with no statistically significant difference in postprandial blood sugars compared to participants in the control group. There were no major hypoglycemic events in either group. The intervention group had 1 verified minor hypoglycemic event and the control group had 5, though this difference was not statistically significant. Although the study authors lauded the improvements in the intervention group's blood sugars during the trial, more patient-oriented outcomes such as hypoglycemia were not significantly different (though it's possible that a better powered trial might have demonstrated a more robust difference). At the very least, though, the FAST tool appears to provide a culturally respectful approach to frame discussions with patients with type 2 diabetes planning to fast during the month of Ramadan.
The accompanying editorial considers whether the FAST trial's findings might also apply to other persons with type 2 diabetes who may be fasting, whether they are required to fast before a procedure or engaging in intermittent fasting with the goal of weight loss. With continued interest by many in intermittent fasting, keeping an open dialogue with our patients about safety and options is of critical importance. This 2015 AFP Curbside Consultation provides additional guidance for supporting patients with type 2 diabetes who choose to fast.
Maintaining connection to social traditions when possible, be they religious or otherwise, can support well-being and resilience during this challenging time. This AFP article on "The Spiritual Assessment" includes several tips for understanding our patients' faith traditions and supports, and the Ethnic Minorities subsection of the AFP By Topic: Care of Special Populations includes additional resources to increase our cultural competency and respect.