Muslim family breaking fast with red dates

Type 2 Diabetes and Fasting: First Study Done in Singapore

An observational study published in the International Journal of Endocrinology (November 2014) has laid the groundwork for further research into the effects of adjusting dosages of diabetes medication in patients who are fasting. It was the first such study to examine the effects of Ramadan fasting on Muslims with Type 2 diabetes in Singapore.

The multi-disciplinary research team included people from Tan Tock Seng Hospital’s (TTSH) Endocrinology and Pharmacy departments, as well as the National University of Singapore (NUS) Department of Pharmacy. The team worked together in 2012 to understand how diabetes medication and fasting affected blood sugar levels.

Managing Diabetes During Ramadan

Diet plays a major role in diabetes control; explains Dr S K Abdul Shakoor, consultant at TTSH Department of Endocrinology and an author of the study. “Understanding the impact of changing diabetes medication dosages during fasting would help clinicians develop more effective care plans, and allow more patients to observe Ramadan safely,” he says.

In fact, some people with diabetes were already altering their doses as part of their own diabetes care — without consulting their doctors — during their fasting days. This was observed by Fellow Researcher, Associate Professor Joyce Lee, clinical pharmacist from the NUS Department of Pharmacy. This was “a risky practice” as patients increased their risk of hyperglycaemia (high blood glucose) or hypoglycaemia (low blood glucose). However, A/Prof Lee also noticed that altering medication dosage, when done correctly, appeared to improve glucose control. So she got in touch with Dr Shakoor, shared her observations, and they agreed to carry out a prospective study together.

Dosage and Diet

Minimalistic setting of medication and water on a wooden board

The team analysed blood tests (HbA1C) and surveys to track blood glucose levels, medication doses, dietary habits and activity levels of 153 TTSH patients, aged 47 to 65 years. HbA1c measures the blood-glucose level average over a period of three months.

According to Ms Melanie Siaw, an NUS graduate student involved in the study, there were challenges faced by the team in recruiting participants for the study: “Some patients were initially not keen to come back for subsequent blood tests and surveys. However, once we built a rapport with them and they understood that the study could benefit the community, they were willing to help,” she says.

Patients with poor control of their diabetes condition (HbA1c levels ≥ 8.5 percent) made up nearly seven in 10 of the study’s participants. Records showed these patients had their medication doses adjusted for the fasting period, as doctors attempted to mimic the physiological secretion of insulin. Adjustments comprised either smaller doses before sahur (pre-fasting meal), increased night-time doses or a complete cessation of medication. There was an improvement in glucose control among these patients.

However, Dr Shakoor believes that altering medication doses alone was not enough to improve glucose control. “The improvement was most likely due to a reduction in food intake,” he says. Dr Shakoor also notes that these improvements in fasting diets were not maintained in the long term after Ramadan. He attributes this to the celebratory nature of Hari Raya Aidilfitri, which marks the end of Ramadan.

Sugar-laden foods that can lead to high blood sugar levels are often heavily consumed during festivities. Conversely, the team observed that doctors did not alter the medication of patients who already had better glucose control. “This may be because such patients were only taking a few drugs or controlling their condition through diet alone,” says Dr Shakoor, adding that these factors made dose adjustments unnecessary. These patients’ blood glucose levels remained consistent throughout and after the Ramadan period. He cautioned that patients should always consult their doctors before making any changes to their medication dosages.

The Road Ahead

Despite the study’s encouraging results about the possible effects of dosage adjustments, the team says that more controlled studies are needed before any conclusive relationships can be determined. These studies also have to record participants’ dietary and activity patterns in absolute figures.

The team is working towards such a study, which is currently being considered by NHG’s Domain Specific Review Board. “We hope that future studies will help doctors and patients work together, to improve diabetes management during Ramadan,” says A/Prof Lee.

  • Type 2 diabetes is largely preventable. Some risk factors, such as being overweight or obese, following an unhealthy diet, insufficient physical activity or smoking.

  • Pre-diabetes is a condition when your blood sugar levels are high, but not high enough for you to be considered as diabetic.

  • Pre-diabetes is reversible with a few lifestyle changes. If you are obese/overweight, lose weight the right way with healthy eating and regular exercise and achieve a healthy body weight.

  • Weight loss can help lower your risk of Type 2 diabetes and heart disease, among other chronic health conditions.

  • If you have Type 1 diabetes or Type 2 diabetes, and plan on intermittent fasting or starting any type of fasting diets, please consult your doctor first. You should not change your medication dosage without consulting your doctor either. The American Diabetes Association doesn't recommend fasting as a technique for diabetes management.

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