Safer Ramadan FASTing for people with diabetes

During the month of Ramadan, Muslims abstain from drinking and eating from dawn to dusk. This fasting is challenging for those with diabetes as it increases the risk of hypoglycaemia, a condition where the blood sugar level becomes abnormally low, which in worsening situations may lead to loss of consciousness, seizures, or even death.

In a recent study led by NUS Pharmacy, researchers demonstrated that Muslims with type 2 diabetes can have better control of their blood sugar levels during Ramadan fasting when they manage their condition together with their healthcare providers using a tool called FAST, or ‘Fasting Algorithm for Singaporeans with Type 2 Diabetes’. It was designed by the NUS team and subsequently reviewed by collaborators from a tertiary hospital and an outpatient health institution in Singapore.

With FAST, Muslims with type 2 diabetes learn how to monitor and control their blood sugar level, so that they can fast safely. It provides those who fast with Ramadan-specific education materials which includes guides on adjusting diet and lifestyle while fasting, as well as a medication dosage modification guide for patients and their doctors.

“Muslims with diabetes are encouraged to actively monitor their blood glucose levels before, during and after fasting so that they can make informed decisions on their self-care such as making adjustments to their diet or doing light exercises. Using FAST, they are also empowered to adjust the dosage of their diabetes medications based on its guidance and in close consultation with their doctors,” shared NUS Pharmacy doctoral student Mr Lum Zheng Kang, who is the co-investigator of the study.

Four times better in controlling blood sugar level 

FAST was first developed in 2016. The NUS team then evaluated the safety and effectiveness of the tool by conducting a randomised controlled trial that involved 97 fasting adults with type 2 diabetes in Singapore. The study was carried out over two Ramadan cycles, in 2017 and 2018. The participants were divided into two groups: a group consisting of 46 patients who used FAST to guide their fasting and a control group of 51 patients who did not use FAST.

The results showed that the three-month average blood sugar level (i.e. HbA1c) of participants who were guided by FAST was four times better than those in the control group that did not use FAST. They also did not experience any major episode of very low blood sugar level. Moreover, even though FAST required closer monitoring and care adjustments, those in the group guided by FAST did not experience additional diabetes distress. Diabetes distress refer to negative emotional responses to the stress of coping with the demands of diabetes management and may be linked to declining health outcomes.

The results of the study were published in the journal Annals of Family Medicine on 9 March 2020.

Promote safe fasting 

The research team’s earlier studies showed that Muslim with diabetes tend to avoid discussing their intention to fast with their healthcare team as they fear the discouragement from the healthcare providers. Also, many healthcare professionals, especially in Muslim-minority settings, tend to advise people with diabetes against fasting instead of providing individualised assessment and advice, due to the lack of cultural and religious understanding and awareness of the needs of these patients.

“In Singapore, there is currently no religious and culturally tailored guide for people with diabetes to manage their condition when they fast during Ramadan. It is important to address this challenge as these patients are at a higher health risk of severe hyperglycaemia (high blood sugar level) and severe hypoglycaemia when they fast during Ramadan. FAST is one of the first tools that addresses these gaps to help Muslims with diabetes to fast safely,” explained Mr Lum, who is the first author of the paper. Severe hyperglycaemia may arise from the over-consumption of food containing carbohydrates, especially when they break fast in the evening, which could cause damage to organs such as the kidneys, heart and eyes. Severe hypoglycaemia may arise from prolonged fasting as well as the effects of their diabetes medicine.

Moving forward, the NUS team will be working on a mobile application version of the tool for people with diabetes, to make it more convenient for patients to guide them in adjusting the dosage of their medication and diet according to their self-monitored blood glucose level results. In addition, the researchers plan to transform FAST into a user-friendly technological tool that can be accessed via electronic medical records to guide healthcare providers in adjusting medication dosages for people with diabetes during the Ramadan fasting period.