When mining data related to the effect of Ramadan fasting on lipid profile, several contradictory results were encountered. According to Adlouni et al.13 Apo-AI increased on day 8 and day 29 of Ramadan Fasting and remained elevated for up to one month later in comparison to baseline values. Together, these cellular and molecular effects lead to endothelial protection and prevention against atherosclerotic diseases.
Diabetes Safety: When managing patients with dyslipidaemia, it is important to consider co-morbidities such as type 2 diabetes mellitus, hypertension, cardiovascular diseases and chronic kidney disease. During Ramadan: Due to major diet changes during Ramadan, patients with dyslipidaemia should pay more attention to their life style habits. The above recommendations should be reinforced in patients with dyslipidaemia during Ramadan because in general there are major alterations in food quality and quantity according to cultural habits. Interestingly, between the Iftar meal and sleeping time, the Tarawih prayer, an optional Ramandan-specific prolonged prayer, is usually performed by Muslims. Finally, precaution for lipid assessment should be taken during Ramadan as the 10 hours overnight fasting before blood sampling for lipid levels might be challenging. Significant progress has been accomplished during the couple of last decades in understanding the mechanisms that govern metabolism regulation during Ramdan fasting as well as the strategies to be followed by patients with metabolic diseases who choose to fast prior, during and upon this Holy month. This journal is a member of and subscribes to the principles of the Committee on Publication Ethics.
ABCD sponsors treatment for those in need regardless of gender, race or creed, helping them to reach their full potential, to live life with dignity and to take their rightful place in their community. ABCD works through local Palestinian partners, the Bethlehem Arab Society for Rehabilitation (BASR) based in Beit Jala, The Sheepfold in Beit Sahour and two UNWRA Refugee Camps in Jalazone and Nour Shams.
Funding is constantly needed for new projects and to update and refurbish existing facilities. It has been previously shown that Ramadan fasting induces favourable changes on metabolic parameters, reduces oxidative stress and inflammation and promotes cardiovascular benefits. The studies in question lead to organizing an international conference in 1996 in Casablanca, Morocco where about 50 papers were presented.2 The current opinion highlighted during the meeting was that Ramadan fasting had beneficial effects on health, especially on some cardiometabolic parameters. Dietary and lifestyle changes remain the only option that helps increase the HDL levels.8 Studying the effects of Ramadan fasting on lipid profile will therefore shed new insight into the impact of such dietary lifestyle changes on Muslim patients who choose to fast.
From the religious aspect, once the day fast is accomplished, there is no restriction on the quantity or quality of food, which is from sunset to sunrise of the following day; this often contributes to the differences noticed in lipid profiles.
However, Apo-B levels were lower during the second and the last week of Ramadan fasting and were maintained at the same level one month after Ramadan fasting. Fasting-triggered increase of HDL may therefore constitute one of the best non-pharmacological methods known to date to significantly improve HDL levels. The current knowledge about risk stratification during Ramadan is restricted to diabetic patients with treatment.36 Based on this stratification, we can consider that patients with stable dyslipidaemia and a pre-Ramadan assessment and educational counseling, can be allowed to fast (Flow Chart-1). Nevertheless, if the use of statin is necessary, they should be started at lowest dose and monitored clinically, and if necessary by checking muscle enzymes. Adapt this dietary pattern to appropriate calorie requirements, personal and cultural food preferences, and nutrition therapy for other medical conditions (including diabetes).
Achieve this pattern by following plans such as the DASH dietary pattern, the USDA Food Pattern, or the AHA Diet.
Nomani (1997)39 has suggested that when energy is limited, a dietary fat increase from 30% to 36% reduces the breakdown of body protein content including labile LDL cholesterol receptors that are protein in nature. Results from several studies reported controversial effects on lipid profiles depending on fluctuant dietary habits, variable physical activity levels and sleep patterns of the patients involved in the studies. A Report on First International Congress "Health and Ramadan" Foundation Hassan II, for Scientific and Medical Research on Ramadan. Celik A, Saricicek E, Saricicek V, Sahin E, Ozdemir G, Bozkurt S,et al.Effect of Ramadanfasting on serum concentration of apelin-13 and new obesity indices in healthy adultmen. Unalacak M, Kara IH, Baltaci D,Erdem O, Bucaktepe PGE.Effects of Ramadan fasting on bio- chemical and hematological parameters and cytokines in healthy and obese individuals.
Ziaee V, Razaei M, Ahmadinejad Z , Shaikh H,Yousefi R,Yarmohammadi L, et al.The changes of metabolic profile and weight during Ramadan fasting. Although ill people are exempted from fasting, most patients with chronic diseases are keen on performing this Islamic-ritual. Total cholesterol intake, as well as total and low-density lipoprotein cholesterol concentrations, increased significantly in non-obese patients with type 2 (n= 57) (p 34 and in type 2 patients with hyperlipidaemia on diet, fibrates or statins.35 Also sleeping habits may be altered and smoking is limited to non fasting time only. Therefore, in order to achieve beneficial effects in the case of patients with dyslipidaemia who decide to fast, a structured pre-Ramadan risk stratification and counseling should be followed. Usefulness of atherogenic dyslipidemia for predicting cardiovascular risk in patients with angiographically defined coronary artery disease.
Cardiovascular disease risk reduction by raising HDL cholesterol - Current therapies and future opportunities. Effect of Ramadan fasting on blood glucose and serum lipid profiles in Libyan diabetic patients. Fasting during Ramadan induces a marked increase in high-density lipoprotein cholesterol and decrease in low-density lipoprotein cholesterol. Ramadanfasting ameliorates oxidative stress and improves glycemic control and lipid profile in diabetic patients.
Concomitant effects of Ramadanfasting and time-of-day on apolipoprotein AI, B, Lp-a and homocysteine responses during aerobic exercise in Tunisian soccer players. Effect of Ramadan fasting on anthropometric parameters and food consumption in 276 type 2 diabetic obese women.
Effect of Ramadan fasting on some indices of insulin resistance and components of the metabolic syndrome in healthy male adults.
Interleukin-6, C-reactive protein and biochemical parameters during prolonged intermittent fasting. Beneficial changes in serum apo A-1 and its ratio to apo B and HDL in stable hyperlipidaemic subjects after Ramadan fasting in Kuwait.
Marked increase in plasma high-density-lipoprotein cholesterol after prolonged fasting during Ramadan.
The Asociación Latinoamericana de Diabetes (Latin American Diabetes Association, ALAD) brought together medical associations in 17 countries in Latin America to produce a consensus statement regarding the treatment of type 2 diabetes. During recent years, Risk stratification and treatment adjustment during Ramadan are well known and structured in several guidelines for patients with diabetes mellitus.
At Sunset, the fast-breaking meal (generally more caloric than the first one) is called Iftar. Additionally, a reinforcement of lifestyle recommendations to prevent cardiovascular risk is needed for patients with dyslipidaemia with or without comorbidities. Effects of Ramadan fasting on cardiovascular risk factors: a prospective observational study.
The goal of the document is to provide practical recommendations that will guide clinicians through a simple decision-making process for managing patients. Data related to the effect of Ramadan fast on lipid profiles are less known and several controversies have been reported.
The cornerstone elements for therapeutic decision making are: severity of hyperglycemia, clinical condition of the patient (stable or with metabolic decompensation), and body mass index. Here, we focus on lipid profile and lipid management during Ramadan taking into account comorbidities and cardiovascular risk.
This is important as it was recently shown that in healthy subjects, the timing of meals is correlated with overall energy intake.40 The same study has demonstrated in multivariate analyses controlling for age, sex, sleep duration, and timing, that eating more frequently, late timing of the last meal, and a shorter duration between last meal and sleep onset, predicted higher total caloric intake. This suggests that eating close to sleep, could lead to weight gain due to a greater number of eating occasions and higher total daily caloric intake. The algorithm is based on the scientific recommendations of the 2006 ALAD guidelines (a document prepared using an evidence-based approach) and data from recent randomized controlled studies. Diabetes and other chronic, non-transmissible diseases are now the leading health problems.
Despite the large and growing number of diabetes cases, this geographic area invests limited financial resources in diabetes care. In the year 2000, the direct cost of diabetes care in Latin America and the Caribbean was approximately US$ 10 billion; minimal when compared to the indirect cost of about US$ 55 billion resulting from disease-related consequences. Most private health insurance plans cover medical assistance, procedures, and hospitalization, but not medication (2-5).
The burden of disease will be even greater in the coming years because the population has a large proportion of young adults living in urban areas and engaged in unhealthy lifestyles. Thus, the impact of diabetes in Latin America is growing fast and the national health systems are unprepared. Such restructuring should be based on the best available clinical evidence, but existing international guidelines should be adapted to reflect the differences and needs of each geographic area. The unique challenges regarding type 2 diabetes treatment in Latin America are a result of the interactions among the area's socioeconomic factors, its variety of cultures and traditions, and its limited health resources. Consensus documents and practice guidelines that are specifically oriented toward the Latin American environment are needed to train and guide primary care physicians. In line with its commission, ALAD called upon leaders and representatives from the endocrine and diabetes associations of 17 countries in Latin America to produce a consensus statement for the treatment of type 2 diabetes mellitus. The participants were divided into three groups; each group discussed and responded to three of the nine questions addressed by the present report. A writing committee prepared the summary, which was approved by all of the endorsing associations' representatives. The final version of the document was prepared and approved by the members of the writing committee.
The algorithm was based on the scientific recommendations of the 2006 ALAD guidelines-a document prepared using an evidence-based approach (6)-and data from recent randomized controlled studies. Also included in this algorithm were the possible clinical scenarios diabetes patients may present and the necessary actions to follow in each case. Additionally, two groups of patients-divided according to the level of glycemic control and clinical condition-are included: Group 1.
These patients constitute a therapeutic challenge; primary care units do not have the resources to manage such cases. Without a multidisciplinary approach and adequately informed medical personnel, patients, and relatives, obese patients with diabetes frequently continue gaining weight and do not achieve treatment goals. The section on obesity emphasizes the importance of helping patients follow a healthy lifestyle before and during the escalation of pharmacological treatment. In type 2 diabetes, the Kumamoto study (7) and the United Kingdom Prospective Diabetes Study (UKPDS) (8, 9) demonstrated significant reductions in microvascular and neuropathic complications with intensive therapy. Similar to the Diabetes Control and Complications Trial-Epidemiology of Diabetes Interventions and Complications (DCCTEDIC) studies' findings (10), long-term follow-up of the UKPDS cohort has recently demonstrated a "legacy effect" of early, intensive glycemic control on long-term rates of microvascular complications. This benefit continues, even if the differences in glycemic control between the intensive and standard cohorts are lost after the end of the study (10, 11). In Latin America, fasting blood glucose (venous or capillary) values are the key elements used by physicians to evaluate their patients and guide decisions. However, in line with other scientific organizations (12-14), glycosylated hemoglobin (HbA1c) is recommended as the optimal method to assess glycemic control. As shown in Table 1, A1c levels can be translated to mean plasma glucose concentrations, making it easier for patients to understand the information. In several large, randomized, prospective clinical trials, treatment regimens that reduced A1C < 7% were associated with fewer long-term microvascular complications. Whereas many studies and meta-analyses (15-17) have shown a direct relationship between A1C and the incidence of cardiovascular events, the potential of intensive glycemic control to reduce cardiovascular mortality has been less clearly defined. Based on current clinical evidence (18-21), an HbA1c < 7% is recommended as the most appropriate level for the majority of patients. In addition, this Consensus highlights plasma lipid and blood pressure goals as prominent objectives of diabetes management (Table 2). Several controlled studies and meta-analyses have shown the benefits of lipid lowering therapies in patients with diabetes.
The concentration of microalbuminuria should be measured annually in all type 2 diabetes patients and in type 1 diabetes patients with disease duration > 5 years.
Microalbuminuria should be treated by achieving blood pressure targets; the use of angiotensinconverting enzyme (ACE) inhibitors inhibitors and angiotensin II receptor blockers have been shown to delay the progression to macroalbuminuria. Drugs currently used in diabetic care, including mean and maximum doses are described in Table 4.
The pharmacological characteristics of insulin preparation and insulin analogues are included in Table 5. Besides its therapeutic effects, Metformin has been shown to decrease cardiovascular complications in retrospective (22, 23) and prospective analyses (8, 9) and has the advantage of being easily accessible for virtually all populations. The eGFR can be estimated by using the Cockcroft-Gault formula (24) or the MRDS equation used in the Diet in Renal Disease Study-recommended by the National Kidney Disease Education Program (United States, 25). However, the risk of hypoglycemia (especially with first generation, long-acting sulfonylureas) and weight gain should be considered (28). The efficacy of sulfonylureas over the longterm is less than that of Metformin and glitazones. Due to their short half-life, meglitinides can be used in patients with renal failure (29). Patients should be carefully selected for this therapeutic option in order to reduce the risk of heart failure, coronary events, or fractures (particularly in postmenopausal women) (30). Gliptins are orally active, safe, and highly tolerable, with a minimal risk for hypoglycemic events. These drugs have been used in combination with Metformin, sulfonylureas, and thiazolidinediones. However, additional evidence is required to assess the long-term effects of the DPP-IV inhibitors, in particular issues such as safety and their effectiveness in the prevention of the diabetes-related chronic complications (32). The decision should be based on cost-effectiveness analysis and individualized patient care. Other options based on Metformin may also be considered at this stage: Metformin + Meglitinides, Metformin + Glitazones, Metformin + DPP-4 inhibitors, and Metformin + Incretin Analogues (6, 28, 35, 36). Options include the use of DPP-IV inhibitors, GLP-1 analogue, or glitazones, in addition to Metformin and a sulfonylurea. The intervention of a diabetes specialist could be considered in patients who are not reaching the treatment targets despite the use of three agents. What should be done to manage overweight patients not controlled by monotherapy and who continue to gain weight? These patients require closer monitoring and the support of a multidisciplinary team, if available, for the implementation of an adequate dietary plan, an exercise program, and psychological support. The use of combination therapy that may provoke weight gain should be limited to cases that remain hyperglycemic despite lifestyle modifications. The timeframe for considering combination therapy will depend on the patient's circumstances (39).
This is due to the progressive decline in insulin secretory capacity that occurs in type 2 diabetes. Initially, control can be achieved with a bedtime dose of Neutral Protamine Hagedorn (NPH) insulin or a long-acting insulin analogue (Glargine or Detemir) in combination with oral agents. The frequency of the adjustments depends on the patient characteristics and the experience of the practitioner. Changes in the dosage on a daily basis may be necessary in severely hyperglycemic patients.
When the treatment goals are close to being achieved, it is better to adjust the amount of insulin every 3-4 days. A time period of at least 1-3 months is recommended to assess whether treatment goals are achieved before considering a change in treatment regime.
Of note, the combination of insulin with glitazones is not recommended due to the increased risk of edema and heart failure.
The choice depends on insulin availability, patient requirements, metabolic behavior, and risk of hypoglycemia. One option is a mixture of 2 types of insulin, such as regular insulin and NPH insulin, or a combination of a short acting insulin analogue (Lispro, Aspart, or Glulisine) with NPH insulin.
Another option is 1-2 doses of a long-acting analogue (Glargine or Detemir) with a dose of regular human insulin or a rapid-acting insulin analogue before each meal. Time of action, peak activity, and duration of different insulins and insulin analogues are shown in Table 5 (40, 41).
At this stage of intensive insulin therapy, referral of the patient to a specialist is recommended. If there is a lack of response after a 1-3 month period, patients should be started on an insulin regimen (42). Any of the insulin regimens described above is useful for the prompt correction of hyperglycemia and nutritional status (43). Later, once these patients are stable and have regained weight, the treatment should be reassessed; the possibility of switching to oral drugs can be considered.
Some cases may be eligible for a more intensive therapeutic regimen with multiple insulin doses or an insulin pump. It is assumed that measures for adopting a healthy lifestyle are in place and reinforced regularly. All therapeutic alternatives should be given a reasonable amount of time to evaluate their maximal efficacy.
This is especially relevant if there is clinical improvement, weight stabilization, and gradual improvement of fasting and post-prandial glucose and HbA1c values. Primary care physicians are discouraged from delaying the addition of an oral glucose-lowering agent or insulin. Clinical inertia is a contributing factor for not achieving treatment targets in all health systems.
In most countries, the primary care physician is responsible for the treatment of a large proportion of the diabetic population. Self-monitoring is a fundamental tool for all patients with diabetes; in particular, those on insulin treatment who require intensive glucose monitoring.
It helps determine whether patients are on the right track for achieving treatment objectives (44). Capillary glucose measurement has become more accessible in Latin America; however, the high cost of glucometers and test strips is still a significant problem for many patients. It must be taken into account, however, that this index is not readily available throughout Latin America, and where it is available, cost is often a deterrent. General practitioners are often responsible for making treatment decisions during the early stages of the disease.
However, it is essential that practitioners aim to achieve the standards of diabetes care in their patients. Continuing medical education for primary care physicians must be a priority for national and international medical institutes. Patients who do not achieve treatment goals within a 6-12 month period should be referred to a specialist.
Training of medical students and primary care physicians should be updated to provide the necessary skills for successfully implementing diabetes care and promoting long-term adherence to therapy (45). In addition, diabetes education programs are needed for both patients and the general public.
If these actions are not implemented, a large percentage of the diabetic population will remain outside of the treatment target levels (45, 46).
They can prepare position documents that guide doctors in achieving better therapeutic results. Latin American countries share many ethnic, social, cultural, and lifestyle characteristics. As such, ALAD has produced specific recommendations for Latin America for the last 40 years. This document was approved and recommended by the Pan American Health Organization (PAHO) as guidelines for Latin America (49). The aim was to integrate the ALAD guidelines with important information from each organization to produce a common standard for diabetes in Latin America. The recommendations are applicable to practically every patient, with some possible exceptions. Acknowledges the importance of reaching treatment targets early, especially in the initial years of the disease.
Includes special notes regarding obese patients who are unable to reach glucose treatment goals and continue to gain weight. Recommends the early use of combination therapy and the timely addition of insulin in patients who do not achieve adequate glucose control. Primary care physicians are discouraged from delaying the addition of an oral glucose lowering agent or insulin because this practice results in prolonged exposure to the adverse effects of hyperglycemia. Describes clinical traits of the available glucose-lowering agents to aid in selecting from among the treatment options. Recognizes that, in Latin America, logistics can limit the use HbA1c determination-the gold standard for glycemic control-and offers regular determination of venous and capillary glycemia as an acceptable alternative. The position statement recommends treatment targets for both HbA1c and fasting glucose levels. In addition, the importance of individual practitioners as providers of diabetes care in Latin America is highlighted. Provides clinical indications and possible contraindications for all of the existing glucose lowering agents. It is the responsibility of each medical institute and ALAD to educate physicians to ensure correct medication usage. Because this consensus takes into account the unique challenges faced by patients and physicians in Latin America, its strategies are more feasible and it is hoped that its impact will go farther than that of past efforts to improve diabetes management. Special emphasis is given to the management of the obese patient with type 2 diabetes not reaching the treatment targets.
With the help of all participating institutions, we expect that this consensus document will be helpful to improving the quality of diabetes care in Latin America. Intensive insulin therapy prevents the progression of diabetic microvascular complications in Japanese patients with non-insulin-dependent diabetes mellitus: a randomized prospective 6-year study. Intensive blood glucose control with sulphonylureas or insulin compared with conventional treatment and risk of complication in patients with type 2 diabetes.
Effect of intensive blood glucose control with Metformin on complication in overweight patients with type 2 diabetes. Canadian Diabetes Association 2008 clinical practice guidelines for the prevention and management of diabetes in Canada. Glycemic control and macrovascular disease in types 1 and 2 diabetes mellitus: meta-analysis of randomized trials. Effect of intensive control of glucose on cardiovascular outcomes and death in patients with diabetes mellitus: a meta-analysis of randomised controlled trials. Decreased mortality associated with the use of Metformin compared with sulfonylurea monotherapy in type 2 diabetes. Reduced cardiovascular morbidity and mortality associated with Metformin use in subjects with type 2 diabetes. Acarbose treatment and the risk of cardiovascular disease and hypertension in patients with impaired glucose tolerance: the STOPNIDDM Trial. Effects of exenatide (exendin-4) on glycemic control and weight over 30 weeks in patients with type 2 diabetes treated with metfomin and a sulfonylurea. Effects of exenatide on glycemic control and weight over 30 weeks in Metformin-treated patients with type 2 diabetes. PRESERVE-B: two year efficacy and safety of initial combination therapy with nateglinide or glyburide plus Metformin. Effect of Metformin and rosiglitazone combination therapy in patients with type 2 diabetes mellitus.
Weight loss reverses secondary failure of oral hypoglycaemic agents in obese non-insulin-dependent diabetic patients independently of the duration of the disease. Approaches to treatment of pre-diabetes and obesity and promising new approaches to type 2 diabetes.
Self monitoring of blood glucose in patients with type 2 diabetes who are not using insulin: a systematic review.
A Multi-Center, Epidemiologic Survey of the Current Medical Practice of General Practitioners Treating Subjets with type 2 Diabetes Mellitus In Latin America. Nathan DM, Buse JB, Davidson MB, American Diabetes Association, European Association for the Study of Diabetes.
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