Adolescent fasting .................pptx

Adolescent fasting

1. Fasting during Ramadan in adolescents with diabetes Dr.Yassin M Alsaleh Consultant Pediatric endocrinologist

2.   قال تعالى: ( وَأَن تَصُومُوا خَيْرٌ لَّكُمْ ۖ إِن كُنتُمْ تَعْلَمُونَ) But to fast is best for you, if you only knew.

3. Introduction Ramadan fasting is one of the five pillars of Islam . Fasting during the month is obligatory for all healthy adult and adolescent Muslims  . Some patients with diabetes, despite their exemption insist on fasting in Ramadan

4. Depending on the geographical location and season, the duration of the daily fast may range from a few to 20 hr

5. Adolescence Adolescence,  transitional phase of growth and development  between  childhood and adulthood. The  World Health Organization (WHO) defines an adolescent as any person between ages 10 and 19.

6. adolescents with T1DM the challenge is greater . Adolescents usually insist on fasting, often without the approval of their physicians. This is may be a reaction against the feeling that due to their disease, they are physiologically different from the healthy adolescent peers . Bedowra Zabeen , Samin Tayyeb. Fasting during Ramadan in adolescents with diabetes. Indian J Endocrinol Metab . 2014 Jan-Feb; 18(1): 44–47.

7. adolescents with T1DM it is important for parents to assume a more secondary supporting role. Giving too much responsibility to children too early is a common mistake. however, not giving appropriate responsibility as young people become more independent can also cause problems.

8. adolescents with T1DM health care and emotional needs of adolscents are distinctly different from others. This phase is frequently associated with a deterioration in metabolic control . Adolescence may be the time when vascular complications first become apparent.

9. adolescents with T1DM Saudi Arabia Among Islamic countries , KSA was found to be the highest, with 71.6% of Type 1 diabetics choosing to fast. Salti I, Bénard E, Detournay B, Bianchi-Biscay M, Le Brigand C, Voinet C, et al. A population-based study of diabetes and its characteristics during the fasting month of Ramadan in 13 countries: results of the epidemiology of diabetes and Ramadan 1422/2001 (EPIDIAR) study. Diabetes Care 2004;27(10):2306–11.

10. safety current evidence has proved that it is safe for diabetics with type 1 over the age of 11 years to fast during Ramadan proper education, appropriate adjustment of the drug regimen, diet control and daily activity should be provided. Majid H Alabbood . The effect of Ramadan fasting on glycaemic control in insulin dependent diabetic patients: A literature review.Diabetes & Metabolic Syndrome: Clinical Research & Reviews. Volume 11, Issue 1, January–March 2017, Ibrahim AlAlwan , Abdulhameed Al Banyan . Effects of Ramadan fasting on children with Type 1 diabetes.International Journal of Diabetes Mellitus (2010) 127–129

11. benefits Fasting during Ramadan is feasible and is associated with significant improvement in HbA1c and fructosamine level in children with T1DM using different insulin regimens. El- Hawary A. Safety and metabolic impact of Ramadan fasting in children and adolescents with type 1 diabetes. J Pediatr Endocrinol Metab . 2016 May 1;29(5):533-41.

12. risks

13. hyperglycemia adolescents with T1DM are at a higher risk of experiencing hyperglycemic events than hypoglycemic events during fasting hours and days. Abdulmoein E. Al-Agha. Flash glucose monitoring system may benefit children and adolescents with type 1 diabetes during fasting at Ramadan. Saudi Med J 2017; Vol. 38 (4): 366-371 Elamin I. E. Abdelgadir . A prospective multi-country observational trial to compare the incidences of diabetic ketoacidosis in the month of Ramadan, the preceding month, and the following month . Journal of Diabetes & Metabolic Disorder(2016) 15:50

14. the incidence of severe hyperglycemia during Ramadan in patients with type 1 diabetes increased threefold A. HASSAN, S.A. Diabetes during Ramadan – PRE-approach model: Presentation, Risk stratification, Education. Eur opean Rev iew for Med ical and Pharmacol ogical Sci ences.18.2014 3x

15. DKA the rates of DKA admission during ramdan and one month after were higher than the average monthly DKA admissions. The duration of acidosis was longer in Ramadan . This is positively correlated with duration of diabetes Elamin I. E. Abdelgadir . A prospective multi-country observational trial to compare the incidences of diabetic ketoacidosis in the month of Ramadan, the preceding month, and the following month . Journal of Diabetes & Metabolic Disorder(2016) 15:50

16. euglycemic diabetic ketoacidosis Real euglycemic diabetic ketoacidosis [DKA; blood glucose <200 mg/ dL (11.1 mmol /L)] is rare, . long-lasting starvation conditions due to intervening diseases in type 1 diabetes mellitus patients may also cause it Baş VN. Diabetic euglycemic ketoacidosis in newly diagnosed type 1 diabetes mellitus during Ramadan fasting. J Pediatr Endocrinol Metab . 2015 Mar;28(3-4):333-5.

17. recommendations There is a paucity of evidence-based medicine in the field of adolescent management of diabetes during Ramadan.

18. Individualization The management plan must be highly individualized educational counseling should focus not only on the patient but also his or her family Highly individualized

19. education In a large observational study (READ), patients who fasted during Ramadan without attending a structured education session had a four-fold increase in hypoglycemic events . Bravis V, Hui E, Salih S, Mehar S, Hassanein M, Devendra D. Ramadan Education and Awareness in Diabetes (READ) programme for Muslims with Type 2 diabetes who fast during Ramadan.  Diabet Med. 2010;27:327–31.

20. Glycemic control before Ramadan in adolescents with T1 DM appears to correlate with blood glucose profile during Ramadan fasting. Afandi B. Correlation between pre- ramadan glycemic control and subsequent glucose fluctuation during fasting in adolescents with Type 1 diabetes. J Endocrinol Invest. 2017 Feb 26.

21. Pre-Ramadan medical assessment Preferably undertaken 1–2 months before the fasting month starts. Physical status, glycemic status, and appropriate blood studies. Look for any acute and chronic complications and individual risk stratification to identify those not fit to fast. Kiswhar Azad. Fasting guidelines for diabetic children and adolescents. Indian J Endocrinol Metab . 2012 Jul-Aug; 16(4): 516–518.

22. very high-risk group One or more Severe hypoglycaemia within the 3 months prior to Ramadan History of recurrent hypoglycaemia History of hypoglycaemia unawareness DKA within the 3 months prior to Ramadan Hyperosmolar hyperglycaemic coma within the 3 months prior to Ramadan Poorly controlled T1DM Acute illness Chronic dialysis or CKD stage 4 & 5 Pregnancy in pre-existing diabetes, or GDM treated with insulin or SUs Mohammed Abdul Jaleel . Ramadan and diabetes: As- Saum (The fasting) Indian J Endocrinol Metab . 2011 Oct-Dec; 15(4): 268–273.

23. Diet and nutrition The common practice of ingesting large amounts of foods rich in carbohydrates and fats, especially at the sunset meal, should be discouraged Inclusion of fruits, vegetables, lentils, yogurt, cereal Fluid should be taken liberally during nonfasting hours .

24. Diet and nutrition (SUHUR) Limitation of sugary food items . Complex carbohydrates are recommended This should be taken as late as possible.

25. Percentage of total calories/day

26. Exercise and physical activity A normal level of activity should be maintained. avoiding excessive activities in the hours before the sunset meal.

27. Breaking the fast sick days

28. Checking glycemic status neither blood testing nor administration of insulin is forbidden and neither is considered to invalidate the fasting state. Patients should be encouraged to do frequent home monitoring. especially before Iftar and 2 h afterwards and before and 2 h after the Suhur . Urine should be checked for ketone if blood glucose is high (>15 mmol /L).

29. Flash glucose monitoring system adolescents with T1DM who use the FGMS could fast without the risk of severe hypoglycemia or DKA during Ramadan. The usage of the FGMS could lead to earlier detection of hypoglycemic and hyperglycemic episodes. Abdulmoein E. Al-Agha. Flash glucose monitoring system may benefit children and adolescents with type 1 diabetes during fasting at Ramadan. Saudi Med J 2017; Vol. 38 (4): 366-371

30. I nsulin  R egimens for  T ype  1 D iabetic   P atients basal-bolus regimen is the preferred protocol of management. Switch to insulin analogues where possible. use carbohydrate counting for meals to match the insulin dose . If glucose rises above , a correcting dose of rapid-acting insulin should be given. Al- Arouj M, Assaad -Khalil S, Buse J, Fahdil I, Fahmy M, Hafez S, et al. Recommendations for management of diabetes during Ramadan: Update 2010. Diabetes Care. 2010;33:1895–902. Mohamed Hassanein.Diabetes and Ramadan: Practical guidelines. Diabetes Res Clin Pract (2017),

31. basal–bolus insulin Reduction of basal insulin by 10–30 % and further if needed and to be given at iftar time. extra

32. Reducing basal insulin during Ramadan fasting does not decrease the risk of symptomatic hypoglycemia. Deeb A, Al Qahtani N,  Does Reducing Basal Insulin During Ramadan Fasting by Children and Adolescents with Type 1 Diabetes Decrease the Risk of Symptomatic Hypoglycemia? Diabetes Technol Ther . 2016 Sep;18(9):539-42

33. Two-dose insulin regimen  the morning insulin dose should be taken at iftar . half of the evening dose should be taken at suhur . 50%

34. Two-dose insulin regimen

35. Insulin degludec   These drugs should be initiated at least 4–6 weeks before start of Ramadan, to ensure dose stabilization is complete before Ramadan begins The degludec   dose may need to be reduced by 25% Sanjay Kalra . Insulin degludec and insulin degludec /insulin aspart in Ramadan: A single center experience. Indian J Endocrinol Metab . 2016 Jul-Aug; 20(4): 564–567.

36. Metformin

37. THANK YOU