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Diabetes and Ramadan
p r i m a r y c a r e d i a b e t e s 9 ( 2 0 1 5 ) 241–243
Contents lists available at ScienceDirect
Primary Care Diabetes journal homepage: http://www.elsevier.com/locate/pcd
Editorial
Diabetes and Ramadan
As of 2010, it has been estimated that there are 1.6 billion Muslims around the world, accounting for almost 23% of the global population. The number of Muslims around the world is projected to increase rapidly in the decades ahead, growing to nearly 2.8 billion in 2050; this is twice as fast as the overall global population growth. Consequently, Muslims are projected to rise from 23% of the world’s population in 2010 to 30% in 2050 [1]. In 2014 the global prevalence of diabetes was estimated to be 9% among adults aged 18+ years [2]. In several Muslim countries the prevalence of diabetes is among the highest in the world [3]. Results from the population-based Epidemiology of Diabetes and Ramadan 1422/2001 (EPIDIAR) study among 12,243 people with diabetes from 13 Islamic countries showed that 43% of patients with type 1 diabetes and 79% of patients with type 2 diabetes fast during Ramadan [4], lead to the estimate that more than 55 million people with diabetes worldwide fast during Ramadan. Ramadan is a lunar-based month, and its duration varies between 29 and 30 days. Muslims who fast during Ramadan must abstain from eating, drinking, use of oral medications, and smoking from predawn to sunset. However, there are no restrictions on food or fluid intake between sunset and dawn. Most people consume two meals per day during this month, one after sunset, referred to in Arabic as Iftar (meal breaking the fast), and the other before dawn, referred to as Suhur (predawn). The length of fasting is dependent on geographic location, lasting for up to 18 h, and is associated with varying degrees of change in feeding and sleep patterns ranging from slight to complete reversal of sleep/wake cycle. Intermittent fasting with adequate sleep duration is reported to improve brain function and cardiometabolic health [5]. Some studies on Ramadan practitioners showed similar results [6–9]. Decreased oxidative stress (as measured by gamma glutamyl transferase), and high sensitivity C-reactive protein (hs-CRP), was also reported in fasting healthy adults [10]. Metabolic stability is maintained usually by the endocrine responses to changes in sleeping and feeding patterns, with increased gluconeogenesis and lipolysis [11]. However, those changes in
sleep/wake and feed/fast cycles create stress, with increased evening cortisol, loss of its circadian normal pattern, and associated insulin resistance [11]. Thus, the hoped for benefits of Ramadan fasting might be overset by the deleterious effects of circadian dysregulation. Fasting is not meant to create excessive hardship on the Muslim person, as clearly mentioned in the Holy Quran. Nevertheless, many people with diabetes still choose to fast during Ramadan, thereby creating a medical challenge for themselves and their health care providers. Considering the above mentioned effects of changed lifestyle on endocrine system, and in particular insulin resistance, it is increasingly important that medical professionals be aware of potential risks associated with fasting during Ramadan and approaches to mitigate those risks. Structured diabetes education is essential and has shown to be a safe and effective tool in managing diabetes during the fasting period and after breaking the fast during Ramadan. In a recent study carried out by a group of investigators from Egypt, Iran, Jordan, and Saudi Arabia on a multi-nation, multi-center, controlled clinical trial of enhanced vs usual diabetes education and management during Ramadan [12]. The trial was conducted at 8 clinical sites (2 in each country: one intervention, and one control clinic). Pre-Ramadan surveys were administered to 1010 people, 857 (85%) of whom also completed post-Ramadan surveys. Of these, 774 reported having type 2 diabetes and were fasting during Ramadan; their age (mean ± SD) was 48 ± 10 years, BMI 30 ± 4 kg/m2 and HbA1c 8.8 ± 1.4%. After Ramadan, patients who had received individualized education were more likely to have modified their diabetes treatment plan during Ramadan (97% vs 88%, p < 0.0001), performed self-monitoring of blood glucose during Ramadan at least twice daily (70% vs 51%, p < 0.0001), and had improved knowledge about hypoglycemic signs and symptoms (p = 0.0007). Those who received individualized education also reduced their body weight (2.9 ± 6.4 kg vs −0.5 ± .6 kg, p < 0.0001) and HbA1c (−0.7 ± 1.1% vs −0.1 ± 1.3%, p < 0.0001) compared with patients in the control clinics during Ramadan. There were more mild (77% vs 67%, p = 0.0031) and moderate (38% vs 19%, p < 0.0001) hypoglycemic events reported in the
242
p r i m a r y c a r e d i a b e t e s 9 ( 2 0 1 5 ) 241–243
intervention group, however the intervention group reported fewer severe hypoglycemic events (23% vs 34%, p = 0.0017). Diabetes education also allows to overcome certain barriers to diabetes care such as the misconception that puncturing one’s skin for blood glucose testing during the fast would break the fast [13]. Contrary to the widespread incorrect belief that injection invalidates the fast, patients should be instructed that insulin injections have no nutrition value and that they are allowed, regardless of whether they are given by subcutaneous, intramuscular or intravenous route. Similarly, there is a popular incorrect belief that pricking finger for point-of-care testing breaks the fast, which many lead to patients skipping glucose testing during Ramadan. Again, patients and family members should be educated that similar to injections, puncturing the skin with glucose monitoring devices are allowed, and they will help in assessing glucose control, and recognising hypoglycaemic events during the Ramadan fast. Much of what is recommended for the management of patients with diabetes during fasting during Ramadan is based on expert opinion and common sense; there are only few RCTs to determine best treatment regimens for patients with diabetes. Yet, since the last consensus publication [14], few studies have reported on the efficacy and safety of some newly developed antidiabetic agents. Recently, a new 2015 update of the consensus report has been published [15]. One of the major recommendations is that diabetic patients should be stratified into their risk of hypoglycaemia and/or the presence of complications prior to the beginning of fasting, keeping in mind the insulin resistance induced by altered lifestyle. Patients at high risk of hypoglycaemia and with multiple diabetic complications should be advised against prolonged fasting. Agents such as metformin, alphaglucosidase inhibitors, thiazolidinediones (TZDs), and dipeptidyl peptidase-4 (DPP4) inhibitors appear to be safe and do not need major dose adjustments. Sulfonylureas should be used with caution during Ramadan, in particular chlorpropamide or glyburide, which are associated with increased risk of hypoglycaemia. The dose of sulfonylureas should be reduced or the medication stopped before the start of the fast depending on the degree of control, kidney function and presence of diabetic complications. There is some knowledge on the efficacy and safety of new agents such as DPP4-inhibitors alone or in combination with metformin therapy; their use appears to be safe and with low rates of hypoglycaemia. The use of glucagon like peptide 1 (GLP-1) receptor agonists may be of benefits for obese patients with diabetes improving glycaemic control and also reducing appetite during Ramadan. Thus far, however no data exist on the safety and efficacy of GLP-1 receptor agonists during the fasting period of Ramadan, and the same applies to more recent therapeutic addition, SGL2-inhibitors. Patients with type 1 and type 2 diabetes treated with insulin should be educated on the appropriate use of insulin and the need for frequent glucose monitoring during the fasting period. Most patients require modification of basal insulin dosage and/or the use of premeal insulin to cover mealtime glucose spikes after breaking the fast. In some patients, a larger insulin dose may be needed after a large evening meal. The use of basal insulin analogs and insulin pumps are of benefit as they cover basal insulin requirements without significant peaks and are associated with less hypoglycemia
compared with human NPH and premixed insulin. Drawback of the use of insulin analogs and insulin pumps is the cost and limitations on technology support in some countries or regions.
references
[1] http://www.globalreligiousfutures.org/religions/muslims (accessed 09.05.15). [2] World Health Organization, Global Health Estimates: Deaths by Cause, Age, Sex and Country, 2000–2012, WHO, Geneva, 2014, Available from: http://www.who.int/mediacentre/factsheets/fs312/en/ (accessed 09.05.15). [3] International Diabetes Federation, Global Burden: Prevalence and Projections, 2014 and 2030, 2014, Available from: http://www.diabetesatlas.org [4] I. Salti, E. Benard, B. Detournay, M. Bianchi-Biscay, C. Le Brigand, C. Voinet, A. Jabbar, EPIDIAR Study Group, 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 27 (2004) 2306–2311. [5] M.P. Mattson, R. Wan, Beneficial effects of intermittent fasting and caloric restriction on the cardiovascular and cerebrovascular systems, J. Nutr. Biochem. 16 (2005) 129–137. [6] A. Adlouni, N. Ghalim, A. Benslimane, J.M. Lecerf, R. Saile, Fasting during Ramadan induces a marked increase in high-density lipoprotein cholesterol and decrease in low-density lipoprotein cholesterol, Ann. Nutr. Metab. 41 (1997) 242–249. [7] A. Adlouni, N. Ghalim, R. Saile, N. Hda, H.J. Parra, A. Benslimane, Beneficial effect on serum apo AI, apo B and Lp AI levels of Ramadan fasting, Clin. Chim. Acta 271 (1998) 179–189. [8] M. Nematy, M. Alinezhad-Namaghi, M.M. Rashed, M. Mozhdehifard, S.S. Sajjadi, S. Akhlaghi, M. Sabery, S.A.R. Mohajeri, N. Shalaey, M. Moohebati, A. Norouzy, Effects of Ramadan fasting on cardiovascular risk factors: a prospective observational study, Nutr. J. 11 (2012) 69, http://dx.doi.org/10.1186. [9] H.M. Al Hourani, M.F. Atoum, S. Akel, N. Hijjawi, S. Awawdeh, Effects of Ramadan fasting on some haematological and biochemical parameters, Jordan J. Biol. Sci. 2 (2009) 103–108. [10] G.M. Ajabnoor, S. Bahijri, A. Borai, A.A. Abdulkhaliq, J.Y. Al-Aama, G.P. Chrousos, Health impact of fasting in Saudi Arabia during Ramadan: association with disturbed circadian rhythm and metabolic and sleeping patterns, PLOS ONE 9 (2014) e96500, http://dx.doi.org/10.1371. [11] S. Bahijri, A. Borai, G. Ajabnoor, A. Abdul Khaliq, I. AlQassas, D. Al-Shehri, G. Chrousos, Relative metabolic stability, but disrupted circadian cortisol secretion during the fasting month of ramadan, PLOS ONE 4 (2013) 1–6. [12] L.N. McEwen, M. Ibrahim, N.M. Ali, S.H. Assaad-Khalil, H.R. Tantawi, G. Nasr, S.M. Moradi, A.A. Misha’l, F.A. Annabi, E.M. Ba-Essa, S.M. Bahijri, J. Tuomilehto, L.A. Jaber, W.H. Herman for the International Group for Diabetes and Ramadan (IGDR), Impact of an individualized type 2 diabetes education program on clinical outcomes during Ramadan, BMJ Open Diabetes Res. Care 3 (2015) (in press). [13] S.N. Masood, M.A. Sheikh, Y. Masood, R. Hakeem, A.S. Shera, Beliefs of people with diabetes about skin prick during Ramadan fasting, Diabetes Care 37 (2014) e68–e69. [14] M. Al-Arouj, S. Assaad-Khalil, J. Buse, I. Fahdil, M. Fahmy, S. Hafez, M. Hassanein, M.A. Ibrahim, D. Kendall, S. Kishawi, A. Al-Madani, A. Ben Nakhi, K. Tayeb, A. Thomas,
p r i m a r y c a r e d i a b e t e s 9 ( 2 0 1 5 ) 241–243
Recommendations for management of diabetes during Ramadan – update 2010, Diabetes Care 33 (2010) 1895–1902. [15] M.A. Ibrahim, M.A. Al Magd, F.A. Annabi, S. Assaad-Khalil, E.M. Ba-Essa, I. Fahdil, S. Karadeniz, T. Meriden, A.A. Misha’l, P. Pozzilli, S. Shera, A. Thomas, S.M. Bahijri, J. Tuomilehto, T. Yilmaz, G.E. Umpierrez on behalf of the International Group for Diabetes and Ramadan (IGDR), Recommendations for management of diabetes during Ramadan: update 2015, BMJ Open Diabetes Res. Care 3 (2015) e000108, http://dx.doi.org/10.1136.
a
Mahmoud Ibrahim a EDC, Center for Diabetes Education, McDonough, GA, USA
a
Suhad Bahijri a King Abdulaziz University, 21589 Jeddah, Saudi Arabia
243
Jaakko Tuomilehto a,b,c,∗ Danube-University Krems, Center for Vascular Prevention, Dr. Karl-Dorrek Strasse 30, A-3500 Krems, Austria b National Institute for Health and Welfare, Mannerheimintie 166, 00271 Helsinki, Finland c King Abdulaziz University, 21589 Jeddah, Saudi Arabia a
∗ Corresponding author. 1751-9918/© 2015 Published by Elsevier Ltd on behalf of Primary Care Diabetes Europe.
http://dx.doi.org/10.1016/j.pcd.2015.06.005
Contents lists available at ScienceDirect
Primary Care Diabetes journal homepage: http://www.elsevier.com/locate/pcd
Editorial
Diabetes and Ramadan
As of 2010, it has been estimated that there are 1.6 billion Muslims around the world, accounting for almost 23% of the global population. The number of Muslims around the world is projected to increase rapidly in the decades ahead, growing to nearly 2.8 billion in 2050; this is twice as fast as the overall global population growth. Consequently, Muslims are projected to rise from 23% of the world’s population in 2010 to 30% in 2050 [1]. In 2014 the global prevalence of diabetes was estimated to be 9% among adults aged 18+ years [2]. In several Muslim countries the prevalence of diabetes is among the highest in the world [3]. Results from the population-based Epidemiology of Diabetes and Ramadan 1422/2001 (EPIDIAR) study among 12,243 people with diabetes from 13 Islamic countries showed that 43% of patients with type 1 diabetes and 79% of patients with type 2 diabetes fast during Ramadan [4], lead to the estimate that more than 55 million people with diabetes worldwide fast during Ramadan. Ramadan is a lunar-based month, and its duration varies between 29 and 30 days. Muslims who fast during Ramadan must abstain from eating, drinking, use of oral medications, and smoking from predawn to sunset. However, there are no restrictions on food or fluid intake between sunset and dawn. Most people consume two meals per day during this month, one after sunset, referred to in Arabic as Iftar (meal breaking the fast), and the other before dawn, referred to as Suhur (predawn). The length of fasting is dependent on geographic location, lasting for up to 18 h, and is associated with varying degrees of change in feeding and sleep patterns ranging from slight to complete reversal of sleep/wake cycle. Intermittent fasting with adequate sleep duration is reported to improve brain function and cardiometabolic health [5]. Some studies on Ramadan practitioners showed similar results [6–9]. Decreased oxidative stress (as measured by gamma glutamyl transferase), and high sensitivity C-reactive protein (hs-CRP), was also reported in fasting healthy adults [10]. Metabolic stability is maintained usually by the endocrine responses to changes in sleeping and feeding patterns, with increased gluconeogenesis and lipolysis [11]. However, those changes in
sleep/wake and feed/fast cycles create stress, with increased evening cortisol, loss of its circadian normal pattern, and associated insulin resistance [11]. Thus, the hoped for benefits of Ramadan fasting might be overset by the deleterious effects of circadian dysregulation. Fasting is not meant to create excessive hardship on the Muslim person, as clearly mentioned in the Holy Quran. Nevertheless, many people with diabetes still choose to fast during Ramadan, thereby creating a medical challenge for themselves and their health care providers. Considering the above mentioned effects of changed lifestyle on endocrine system, and in particular insulin resistance, it is increasingly important that medical professionals be aware of potential risks associated with fasting during Ramadan and approaches to mitigate those risks. Structured diabetes education is essential and has shown to be a safe and effective tool in managing diabetes during the fasting period and after breaking the fast during Ramadan. In a recent study carried out by a group of investigators from Egypt, Iran, Jordan, and Saudi Arabia on a multi-nation, multi-center, controlled clinical trial of enhanced vs usual diabetes education and management during Ramadan [12]. The trial was conducted at 8 clinical sites (2 in each country: one intervention, and one control clinic). Pre-Ramadan surveys were administered to 1010 people, 857 (85%) of whom also completed post-Ramadan surveys. Of these, 774 reported having type 2 diabetes and were fasting during Ramadan; their age (mean ± SD) was 48 ± 10 years, BMI 30 ± 4 kg/m2 and HbA1c 8.8 ± 1.4%. After Ramadan, patients who had received individualized education were more likely to have modified their diabetes treatment plan during Ramadan (97% vs 88%, p < 0.0001), performed self-monitoring of blood glucose during Ramadan at least twice daily (70% vs 51%, p < 0.0001), and had improved knowledge about hypoglycemic signs and symptoms (p = 0.0007). Those who received individualized education also reduced their body weight (2.9 ± 6.4 kg vs −0.5 ± .6 kg, p < 0.0001) and HbA1c (−0.7 ± 1.1% vs −0.1 ± 1.3%, p < 0.0001) compared with patients in the control clinics during Ramadan. There were more mild (77% vs 67%, p = 0.0031) and moderate (38% vs 19%, p < 0.0001) hypoglycemic events reported in the
242
p r i m a r y c a r e d i a b e t e s 9 ( 2 0 1 5 ) 241–243
intervention group, however the intervention group reported fewer severe hypoglycemic events (23% vs 34%, p = 0.0017). Diabetes education also allows to overcome certain barriers to diabetes care such as the misconception that puncturing one’s skin for blood glucose testing during the fast would break the fast [13]. Contrary to the widespread incorrect belief that injection invalidates the fast, patients should be instructed that insulin injections have no nutrition value and that they are allowed, regardless of whether they are given by subcutaneous, intramuscular or intravenous route. Similarly, there is a popular incorrect belief that pricking finger for point-of-care testing breaks the fast, which many lead to patients skipping glucose testing during Ramadan. Again, patients and family members should be educated that similar to injections, puncturing the skin with glucose monitoring devices are allowed, and they will help in assessing glucose control, and recognising hypoglycaemic events during the Ramadan fast. Much of what is recommended for the management of patients with diabetes during fasting during Ramadan is based on expert opinion and common sense; there are only few RCTs to determine best treatment regimens for patients with diabetes. Yet, since the last consensus publication [14], few studies have reported on the efficacy and safety of some newly developed antidiabetic agents. Recently, a new 2015 update of the consensus report has been published [15]. One of the major recommendations is that diabetic patients should be stratified into their risk of hypoglycaemia and/or the presence of complications prior to the beginning of fasting, keeping in mind the insulin resistance induced by altered lifestyle. Patients at high risk of hypoglycaemia and with multiple diabetic complications should be advised against prolonged fasting. Agents such as metformin, alphaglucosidase inhibitors, thiazolidinediones (TZDs), and dipeptidyl peptidase-4 (DPP4) inhibitors appear to be safe and do not need major dose adjustments. Sulfonylureas should be used with caution during Ramadan, in particular chlorpropamide or glyburide, which are associated with increased risk of hypoglycaemia. The dose of sulfonylureas should be reduced or the medication stopped before the start of the fast depending on the degree of control, kidney function and presence of diabetic complications. There is some knowledge on the efficacy and safety of new agents such as DPP4-inhibitors alone or in combination with metformin therapy; their use appears to be safe and with low rates of hypoglycaemia. The use of glucagon like peptide 1 (GLP-1) receptor agonists may be of benefits for obese patients with diabetes improving glycaemic control and also reducing appetite during Ramadan. Thus far, however no data exist on the safety and efficacy of GLP-1 receptor agonists during the fasting period of Ramadan, and the same applies to more recent therapeutic addition, SGL2-inhibitors. Patients with type 1 and type 2 diabetes treated with insulin should be educated on the appropriate use of insulin and the need for frequent glucose monitoring during the fasting period. Most patients require modification of basal insulin dosage and/or the use of premeal insulin to cover mealtime glucose spikes after breaking the fast. In some patients, a larger insulin dose may be needed after a large evening meal. The use of basal insulin analogs and insulin pumps are of benefit as they cover basal insulin requirements without significant peaks and are associated with less hypoglycemia
compared with human NPH and premixed insulin. Drawback of the use of insulin analogs and insulin pumps is the cost and limitations on technology support in some countries or regions.
references
[1] http://www.globalreligiousfutures.org/religions/muslims (accessed 09.05.15). [2] World Health Organization, Global Health Estimates: Deaths by Cause, Age, Sex and Country, 2000–2012, WHO, Geneva, 2014, Available from: http://www.who.int/mediacentre/factsheets/fs312/en/ (accessed 09.05.15). [3] International Diabetes Federation, Global Burden: Prevalence and Projections, 2014 and 2030, 2014, Available from: http://www.diabetesatlas.org [4] I. Salti, E. Benard, B. Detournay, M. Bianchi-Biscay, C. Le Brigand, C. Voinet, A. Jabbar, EPIDIAR Study Group, 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 27 (2004) 2306–2311. [5] M.P. Mattson, R. Wan, Beneficial effects of intermittent fasting and caloric restriction on the cardiovascular and cerebrovascular systems, J. Nutr. Biochem. 16 (2005) 129–137. [6] A. Adlouni, N. Ghalim, A. Benslimane, J.M. Lecerf, R. Saile, Fasting during Ramadan induces a marked increase in high-density lipoprotein cholesterol and decrease in low-density lipoprotein cholesterol, Ann. Nutr. Metab. 41 (1997) 242–249. [7] A. Adlouni, N. Ghalim, R. Saile, N. Hda, H.J. Parra, A. Benslimane, Beneficial effect on serum apo AI, apo B and Lp AI levels of Ramadan fasting, Clin. Chim. Acta 271 (1998) 179–189. [8] M. Nematy, M. Alinezhad-Namaghi, M.M. Rashed, M. Mozhdehifard, S.S. Sajjadi, S. Akhlaghi, M. Sabery, S.A.R. Mohajeri, N. Shalaey, M. Moohebati, A. Norouzy, Effects of Ramadan fasting on cardiovascular risk factors: a prospective observational study, Nutr. J. 11 (2012) 69, http://dx.doi.org/10.1186. [9] H.M. Al Hourani, M.F. Atoum, S. Akel, N. Hijjawi, S. Awawdeh, Effects of Ramadan fasting on some haematological and biochemical parameters, Jordan J. Biol. Sci. 2 (2009) 103–108. [10] G.M. Ajabnoor, S. Bahijri, A. Borai, A.A. Abdulkhaliq, J.Y. Al-Aama, G.P. Chrousos, Health impact of fasting in Saudi Arabia during Ramadan: association with disturbed circadian rhythm and metabolic and sleeping patterns, PLOS ONE 9 (2014) e96500, http://dx.doi.org/10.1371. [11] S. Bahijri, A. Borai, G. Ajabnoor, A. Abdul Khaliq, I. AlQassas, D. Al-Shehri, G. Chrousos, Relative metabolic stability, but disrupted circadian cortisol secretion during the fasting month of ramadan, PLOS ONE 4 (2013) 1–6. [12] L.N. McEwen, M. Ibrahim, N.M. Ali, S.H. Assaad-Khalil, H.R. Tantawi, G. Nasr, S.M. Moradi, A.A. Misha’l, F.A. Annabi, E.M. Ba-Essa, S.M. Bahijri, J. Tuomilehto, L.A. Jaber, W.H. Herman for the International Group for Diabetes and Ramadan (IGDR), Impact of an individualized type 2 diabetes education program on clinical outcomes during Ramadan, BMJ Open Diabetes Res. Care 3 (2015) (in press). [13] S.N. Masood, M.A. Sheikh, Y. Masood, R. Hakeem, A.S. Shera, Beliefs of people with diabetes about skin prick during Ramadan fasting, Diabetes Care 37 (2014) e68–e69. [14] M. Al-Arouj, S. Assaad-Khalil, J. Buse, I. Fahdil, M. Fahmy, S. Hafez, M. Hassanein, M.A. Ibrahim, D. Kendall, S. Kishawi, A. Al-Madani, A. Ben Nakhi, K. Tayeb, A. Thomas,
p r i m a r y c a r e d i a b e t e s 9 ( 2 0 1 5 ) 241–243
Recommendations for management of diabetes during Ramadan – update 2010, Diabetes Care 33 (2010) 1895–1902. [15] M.A. Ibrahim, M.A. Al Magd, F.A. Annabi, S. Assaad-Khalil, E.M. Ba-Essa, I. Fahdil, S. Karadeniz, T. Meriden, A.A. Misha’l, P. Pozzilli, S. Shera, A. Thomas, S.M. Bahijri, J. Tuomilehto, T. Yilmaz, G.E. Umpierrez on behalf of the International Group for Diabetes and Ramadan (IGDR), Recommendations for management of diabetes during Ramadan: update 2015, BMJ Open Diabetes Res. Care 3 (2015) e000108, http://dx.doi.org/10.1136.
a
Mahmoud Ibrahim a EDC, Center for Diabetes Education, McDonough, GA, USA
a
Suhad Bahijri a King Abdulaziz University, 21589 Jeddah, Saudi Arabia
243
Jaakko Tuomilehto a,b,c,∗ Danube-University Krems, Center for Vascular Prevention, Dr. Karl-Dorrek Strasse 30, A-3500 Krems, Austria b National Institute for Health and Welfare, Mannerheimintie 166, 00271 Helsinki, Finland c King Abdulaziz University, 21589 Jeddah, Saudi Arabia a
∗ Corresponding author. 1751-9918/© 2015 Published by Elsevier Ltd on behalf of Primary Care Diabetes Europe.
http://dx.doi.org/10.1016/j.pcd.2015.06.005