<scp>ISPAD</scp> Clinical Practice Consensus Guidelines 2022: Ramadan and other religious fasting by young people with diabetes

Abstract

Fasting is advised, with variable rules, in healthy adults and adolescents in different religions. A common purpose of fasting in these religions is to gain self-restraint, arouse spiritual consciousness, and better understand the plight of the poor and hungry. In this section, general rules and religious guidance on observing and breaking fasting in different religions are given, with emphasis on potential effects on health and glycemic outcomes in children and adolescents with T1D who choose to fast. Ramadan fasting is one of the five pillars of Islam and is obligatory for all healthy adult and adolescent Muslims from the time of completing puberty.1 As per the Islamic rules and guidance from Sunnah (the way of prophet Mohamed), an individual becomes subject to Shari'a rulings that apply when specific features of puberty are attained. Approximately 1.9 billion Muslims celebrate the ninth month of the Hijri (lunar) calendar notable for Ramadan fasting all over the world.2 The Epidemiology of Diabetes and Ramadan (EPIDIAR), a population-based study conducted in 13 countries and involving almost 13,000 adults with diabetes, showed that 78.7% of individuals with type 2 diabetes (T2D) and 42.8% of those with T1D fast for at least for 15 days during Ramadan. Saudi Arabia had the maximum number of individuals with T1D who chose to fast.3 The duration of fasting during Ramadan varies based on geographical location and season but is mandated to be between dawn and dusk. During this period, people who fast abstain from eating, drinking, use of oral medications, and smoking. There are no restrictions on food or fluid intake between dusk and dawn.1, 4 Fasting during Ramadan is not intended to bring excessive difficulty or cause any adverse effect to the individual. Islam has allowed many categories of people to be exempted from fasting; for example, menstruating, pregnant or breastfeeding women, prepubertal children, the elderly, individuals with any acute or chronic illness in whom fasting would be detrimental to health, individuals with an intellectual disability, or individuals who are traveling.1 These principles formed the basis of all the consensus statements by several groups.5-7 The provisions of al-Fitr (i.e., Not to observe the fast) in Ramadan apply if there is any sickness, according to the Almighty saying: “Whoever of you is sick or on a journey, and some of the other days, and on those who support him, ransom poor food.”1 Therefore, if a person fasts and experiences harm or serious hardship while fasting, he/she may be committing a sin.4 Various beliefs exist regarding diabetes management practices during Ramadan. In a study of fasting during Ramadan that included 800 individuals with diabetes, 67% indicated that pricking the skin to measure BGLs breaks the fast.8 Such a belief might endanger individuals with diabetes and predispose them to acute complications. Medical counseling and liaison with Islamic scholars can help correct wrong interpretation as well as understanding and ensure safer fasting. Although some experts would consider fasting, particularly during Ramadan, a practice at high risk for metabolic deterioration, recent studies have demonstrated that individuals with T1D can fast safely during Ramadan, provided they comply with the fasting-focused management plan and are under close professional supervision.6, 9 The Eastern Christian Orthodox Church is the second-largest Christian church, with ~300 million members.10 Orthodox Fasting (OF) is a basic and traditional component of the religion, practiced by a large proportion of the Orthodox population.11 OF includes three main fasting periods: 40 days prior to Christmas, 48 days prior to Easter, 14 days prior to Assumption, along with the fasting period prior to the feast of the Holy Apostles (lasting from 0 to 30 days depending on Easter feast), three other daily feasts (January 5, August 29, September 14), as well as every Wednesday and Friday. Individuals 18–59 years old are expected to fast during these periods. OF is a kind of periodical diet which recommends abstaining from meat, dairy products and eggs for about 180 days annually, and also abstaining from fish for 155 days. The diet during periods of fasting is characterized by increased consumption of cereals, legumes, fruits, vegetables, nuts and seafood. For this reason, it may be considered as a vegetarian dietary pattern, where fasting and non-fasting periods alternate, sharing common features with the classical Mediterranean Diet.11, 12 Studies on OF followers conducted in three different countries (Greece, United States, and Egypt), reported low total energy intake, low fat (total, saturated and trans), low animal and high vegetable protein intake, high complex carbohydrate and fiber intake, high vitamin C, folate and magnesium intake, low calcium and vitamin D intake during different fasting periods.13, 14 The OF meal plan tends to be high in carbohydrate content. Thus, it is advisable for people with T1D to choose carbohydrates with a low glycemic index, and consume them in combination with fiber, proteins (legumes, seafood) or fats (olive oil). Rye, barley, oats, brown rice, quinoa or amaranth are also suitable.15 Although data on the effect of OF diet on metabolic health are heterogenous, a potential benefit on lipid profile has been suggested, whereas there are no data on the effects on cardiovascular and musculoskeletal outcomes. Negative aspects of OF, primarily attributed to dietary limitations of specific vitamins (D and B12) and minerals (calcium and iron), should not be ignored, and relevant guidance might be provided to people following OF by health care professionals.13 Yom Kippur fasting is a major fast and the holiest day in the Jewish religion and calendar.16 It is obligatory for all healthy adult and adolescent Jews from the age of 13 years in males and 12 years in females. All observant and most non-observant Jews practice this 25 fasting. It at dusk of the ninth of month of the Jewish and on the following day of at The during this fast and Jewish includes five other days of fasting between dawn and and these are practiced by observant During fasting, Jews abstain from eating, drinking, and smoking. Fasting is not intended to cause any adverse effect to the Jewish many categories of people to be exempted from fasting; for example, prepubertal children, in and days, individuals with in whom fasting may be detrimental to health, and individuals with an intellectual Jewish an where people who to fast to health can of 30 in with a time Various for diabetes management during fasting have been prior to the of and people with diabetes from fasting. 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