ESPE Yearbook of Paediatric Endocrinology

To read the full abstract: Diabetes Res Clin Pract 2019; 150: 274–281. doi: 10.1016/j.diabres.2018.12.014

• An online survey was sent to physicians registered with the Arab Society for Paediatric Endocrinology and Diabetes (ASPED) to assess the attitudes of health professionals in the management of Type 1 diabetes during Ramadan.• There were 167 responders (86% were pediatricians, 14% were adult physicians).• Almost 80% of the physicians would allow their patients to fast. Attitudes varied markedly among the health professionals surveyed (mainly pediatricians) regarding the prevention and management of both hypo- and hyperglycemia.

The results of the survey show that close to 80% of the surveyed physicians would allow patients to fast. Only a small majority (61%) emphasized the importance of providing education before fasting. Those with hypoglycemia unawareness were considered as high-risk patients for fasting by 47% of physicians. A majority (62%) felt that fasting should be broken if symptomatic hypoglycemia develops. In terms of management, a majority of respondents would decrease basal insulin by 25%, would recommend several dietary adjustments and would use rapid-acting insulin analogs and carbohydrate counting. This article is relevant to pediatric endocrinologists all over the world who care for Muslim children and adolescents with Type 1 diabetes. It complements another article (reference) that provides guidelines for the management of Type 1 (and Type 2) diabetes during Ramadan fasting. The survey shows that the attitudes towards Ramadan fasting vary widely between health professionals not only regarding the criteria required for permission to fast safely but also regarding the management guidelines. I had the opportunity of discussing this interesting issue with a Muslim colleague who also has Type 1 diabetes in order to better understand her point of view. First, she mentioned that, although Ramadan fasting is a pillar of Islam, it is very clearly written that fast can be broken if it may lead to self-harm, such as with diabetes. It is a sin to harm yourself in these circumstances. However, not fasting, or eating food in public, even for permitted reasons, can result in bullying of the children and can lead to discrimination, emphasizing the importance of social norms and of education. Second, it is clearly taught that injecting insulin is not regarded as breaking the fast. In contrast, injecting glucagon or IV glucose is considered as breaking the fast, although it is, as mentioned above, permitted in patients with Type 1 diabetes. Finally, the survey appropriately mentions that monitoring of Type 1 diabetes must be more stringent during fasting. However, for patients in resource-limited settings who have access only to human insulin, or for those who cannot afford to pay for more than 1–2 strips a day, optimizing diabetes management is more challenging than for those who have access to insulin pump, long-acting analogues, appropriate number of glucose strips or glucagon. Thus, proposing the most appropriate options for Ramadan fasting needs to take into account the individual circumstances of each patient and family.

Reference:

1. Deeb A, Elbarbary N, Smart C, Beshyah SA, Habeb A, Kalra S, Al Alwan I, Babiker A, Al Amoudi R, Pulungan AB, Hu-mayun K, Issa U, Yazid M, Sanhay R, Akanov Z, Krogvold L, de Beaufort C. ISPAD Clinical Practice Consensus Guidelines: Fasting Ramadan by young people with Diabetes. Pediatr Diabetes. 2020;21:5–17. doi: 10.1111/pedi.12920.