Glucose homeostasis during ramadan fasting: First case series illustrated by flash glucose monitoring and ambulatory glucose profiling

Abstract

Background: The impact of fasting during the month of Ramadan, practiced by adult Muslims, on glucose homeostasis has attracted much attention recently with view to understanding the metabolic price of fasting and to help plan rational management. The flash glucose monitoring (FGM) expressed as ambulatory glucose profiles (AGP) provides a minimally invasive yet comprehensive insight into blood glucose (BG) changes in relationship to various physiological and behavioral factors. Objectives: To investigate the BG homeostasis during Ramadan fasting in a group of individuals with different states of glucose tolerance. Methods: Eight individuals who were fasting during Ramadan were studied by FGM using the Abbott's FreeStyle® Libre™ system. They included individuals with normal glucose tolerance during pregnancy (1), prediabetes (2), postbariatric hypoglycemia (1) and type 2 diabetes mellitus (4). Results: In the normal pregnancy AGP's fluctuated minimally around meals with some asymptomatic low BG readings on prolonged fasting. In those with prediabetes, most of the daytime BG were within normal but there was a minimal post-prandial rises and some asymptomatic lower readings on prolonged fasting too. In the case of the patient with history of post-bariatric hypoglycemia, daytime fasting periods had perfectly stable normal BG. However, marked early postprandial hyperglycemia occurred in the evening followed by a short-lived symptomatic hypoglycemia. In the 4 patients with diabetes, AGP showed high glucose exposure, wide variation and marked instability after both traditional meals of dawn time (Suhor) and sunset (Iftar) particularly in the later. A variably slow downward trend throughout the day was observed. The differences in the AGP's reflected both biological and behavioral differences between patients within the general picture. AGP's before, during and after Ramadan in 3 patients revealed distinctly-different profiles reflecting the Middle Eastern meal pattern, Ramadan meal pattern and Eid feasting respectively. For patients these findings were discussed

Ramadan fasting and diabetes in adolescents and children: A narrative review

“…Several studies focused on the changes in glucose homeostasis during Ramadan fasting. [16][17][18][19][20][21][22] The salient findings are summarized in Table 1. It is noteworthy that some of these studies were mixed or conducted in adults; however, they remain valuable for the present discussion.…”

“…BG rises predictably and invariably after the first evening meal to variable durations, mounts a smaller postprandial rise after the predawn meal and demonstrates a progressive declining leading to the end of the fasting period [Figure 1]. [20] However, it is the order of magnitude of these changes in relationship to meals and medications that has been the focus of the management maneuvers.…”

“…Using the flash glucose monitoring (FGM), the first comprehensive demonstration of glucose changes during Ramadan fasting using FGM was reported in a small cohort included individuals with different glucose intolerance states. [20] Also, Al-Agha et al [46] reported on 51 participants from a pediatric diabetes clinic during Ramadan. They were able to fast for 67.0% of the total days eligible for fasting, whereas they did not fast on 33% of the days due to either hypoglycemia (15.4%) or nondiabetes-related reasons (17.6%).…”

“…The mean age was 16 ± 3 years, and mean glycated hemoglobin was 8.6% ±1.2%, mean glucose level was 200 ± 84 mg/dl (11.1 ± 4.7 mmol/L), and the overall time spent in hypoglycemia was 5.7% ± 3.0%. The average daily time spent in hypoglycemia was 1.39 h [19,20] per patient. The incidence of hypoglycemia was 0% from 19:00 to 23:00 p.m. and 69% from 11:00 to 19:00.…”

“…The incidence of hypoglycemia was 0% from 19:00 to 23:00 p.m. and 69% from 11:00 to 19:00. Analysis of hypoglycemia revealed [20,21] that 65% was between 61 and 70 mg/dl and 8% lower than 50 mg/dl. As the use of FGM increases, more confidence and perhaps safety may be felt by patients, and more insights into glucose homeostasis at different times of the day during fasting may be gained.…”