|Year : 2021 | Volume
| Issue : 2 | Page : 64-68
COVID-19 lockdown and hypoglycemia among patients with diabetes fasting the month of Ramadan 2020
Zahra Abdulkareem Ghareeb1, Zainab Al Saffar1, Ghadeer Al Ghareeb2, Ghalia Jassam Almaalu1, Alia Alnaj2
1 Department of Internal Medicine, Qatif Central Hospital, Qatif, Eastern Province, Saudi Arabia
2 Department of Qatif Public Health, Qatif Primary Health Care Centers, Qatif, Eastern Province, Saudi Arabia
|Date of Submission||20-Jan-2021|
|Date of Decision||14-Mar-2021|
|Date of Acceptance||20-Mar-2021|
|Date of Web Publication||01-Jun-2021|
Dr. Zahra Abdulkareem Ghareeb
Department of Medicine, Qatif Central Hospital, Qatif
Source of Support: None, Conflict of Interest: None
Background: Patients with diabetes are targeted with diabetes education 8–10 weeks before Ramadan to have a safe fasting experience. In 2020, this timing coincided with COVID-19 lockdown when virtual clinics were implemented to secure patient care continuity. Objectives: We evaluated hypoglycemia episodes among patients with diabetes fasting in Ramadan 2020 during COVID-19 lockdown. Patients and Methods: A cross-sectional study was conducted after the month of Ramadan 2020, using a self-administered online questionnaire and convenient sampling methods. Patients with diabetes aged 14 years and older who practiced fasting in Ramadan were included in the study. Hypoglycemia rate in total and diabetes treatment among observers of Ramadan 2019 and Ramadan 2020 were compared. Predictors of hypoglycemia during fasting Ramadan 2020 were estimated. Results: Out of 367 patients with diabetes aged 14 years and older, 326 (88.8%) participants had the ability to fast Ramadan and were included in the study. Comparing patients' experience in Ramadan 2019 and Ramadan 2020, participants reported lower hypoglycemia episodes during Ramadan 2020 than Ramadan 2019, P = 0.017. In subgroup analysis based on the type of treatment, patients on noninsulin treatment had statistically significant lower hypoglycemia episodes during Ramadan 2020 than Ramadan 2019 (P = 0.006). Patients on insulin treatment had fewer hypoglycemia episodes during Ramadan 2020 than Ramadan 2019, but the difference was not statistically significant (P = 0.405). The probability of hypoglycemia during fasting Ramadan 2020 was higher among younger age groups 14–30 years (odds ratio [OR] 7.24, 95% confidence interval [CI] 1.72–30.39), patients aged 31–45 years (OR 7.18, 95% CI 1.97–26.19), patients with longer duration of diabetes (more than 10 years) (OR 2.30, 95% CI 1.01–5.26), and patients on insulin (OR 14.14, 95% CI 1.72–30.39). Conclusions: COVID-19 pandemic and lockdown did not affect the diabetes-related experience among participants' fasting Ramadan. The hypoglycemia episodes of patients with diabetes in Saudi Arabia were improved during the pandemic era. This could be related to telemedicine services. More studies are required to support its role in improving health conditions beyond our population's pandemic era.
Keywords: COVID-19, hypoglycemia, insulin, lockdown, pandemics, telemedicine
|How to cite this article:|
Ghareeb ZA, Saffar ZA, Ghareeb GA, Almaalu GJ, Alnaj A. COVID-19 lockdown and hypoglycemia among patients with diabetes fasting the month of Ramadan 2020. J Diabetes Endocr Pract 2021;4:64-8
|How to cite this URL:|
Ghareeb ZA, Saffar ZA, Ghareeb GA, Almaalu GJ, Alnaj A. COVID-19 lockdown and hypoglycemia among patients with diabetes fasting the month of Ramadan 2020. J Diabetes Endocr Pract [serial online] 2021 [cited 2022 Dec 5];4:64-8. Available from: https://www.jdeponline.com/text.asp?2021/4/2/64/317425
| Introduction|| |
Since the World Health Organization had announced the outbreak of severe acute respiratory (syndrome coronavirus-2), later named COVID-19 as a pandemic on March 11, 2020, COVID-19 cases and daily deaths have led to worldwide lockdown and restrictions for social distancing as a measure to limit virus spread. During the pandemic, to maintain consistent care for patients with diabetes at the same time to limit the spread of infection through social distancing, methods such as telemedicine had been evaluated for their potential role in improving health outcome and proved its benefit., In Saudi Arabia, during the COVID-19 pandemic, the government imposed a quarantine to limit the outbreak from March 8 to June 21, 2020, which had included the period before, during, and after the month of Ramadan. During the same lockdown timing, the government had implemented virtual clinics and promoted telemedicine. Ramadan is the lunar month when all healthy adult Muslims fast from dawn to dusk. All healthy Muslim adults must fast in Ramadan each year. They abstain from eating or drinking during day time for the whole month. Certain groups of Muslims are exempted from fasting, including high-risk diabetic patients. Despite the exemption, many patients choose to fast, which make a challenge to their health. Patients with diabetes who attempt to fast are at increased risk of hypoglycemia, hyperglycemia, dehydration, and increased thromboembolism. Targeted diabetes education is recommended before, during, and after Ramadan to reduce the risk of such complications aimed at patients who will practice fasting for a safe fasting experience., The aims of the education are to stratify patient risk of fasting and to make an adjustment to medications to limit complications such as hypoglycemia as recommended by the International Diabetes Federation and Diabetes and Ramadan Alliance guidelines. In our study, we assessed telemedicine's effect during the lockdown in achieving this goal by reviewing the rate of hypoglycemia among patients with diabetes who attempted fasting Ramadan 2020 and comparing it to their fasting experience in 2019.
| Patients and Methods|| |
A cross-sectional study was conducted after the month of Ramadan 2020, using a self-administered online questionnaire and convenient sampling methods. Patients with diabetes aged 14 years and older who can practice fasting in Ramadan were included in the study. Filling out the online questionnaire by the participants was considered as consent for participation.
The questionnaire contained three parts. The first part pertained to demographic and personal medical data, including sex, age, type of diabetes, duration of diabetes, type of treatment, diabetes complications, comorbidities, number of blood glucose test performed in months other than Ramadan, and fasting ability. The second and third parts comprised questions about diabetes fasting Ramadan 2019/1440 and 2020/1441. These include the ability to consult a doctor before Ramadan by 2–3 months, measuring blood sugar, continue fasting in Ramadan, able to continue fasting without a problem from diabetes, forced to stop fasting due to hypoglycemia, and having hypoglycemia of <70 mg/dl.
Data analysis was performed using SPSS program version 20 (IBM Corp. in Armonk, NY, USA). Baseline data were presented in descriptive statistics using numbers and percentages. A P < 0.05 (two-tailed) was chosen as a level of significance. Patients who were able to fast and not able to fast were compared using the Chi-square test. Hypoglycemia rate and other diabetes-related experiences among participants' Ramadan 2019 and Ramadan 2020 were compared using the McNemar test. Subgroup analysis of hypoglycemia rate based on the type of diabetes treatment among participants' Ramadan 2019 and Ramadan 2020 was done using the McNemar test. Predictors of hypoglycemia during fasting Ramadan 2020 were estimated using a logistic regression model.
| Results|| |
Of the 367 patients with diabetes, 246 (67.0%) were female; 77 (21.0%) aged 14–30 years and 48 (13.1%) aged >60 years; 150 (40.9%) had Type 1 diabetes mellitus and 178 (48.5%) had Type 2 diabetes; 172 (46.9%) had diabetes mellitus for >10 years; 145 (39.5%) were only on oral hypoglycemic agents and 126 (34.3%) were only on insulin; 131 (35.7%) had diabetes complication; 171 (46.6%) had comorbidities; on months other than Ramadan, 177 (48.2%) measure their blood glucose <1 time/day and 67 (18.3%) measure their blood glucose >3 times/day; and 326 (88.8%) participants had the ability to fast Ramadan [Table 1].
Fasting ability was significantly lower among younger age group (P = 0.003), female gender (P = 0.022), patients with Type 1 diabetes (P = 0.001), patients on insulin (P = 0.001), and those who measure their blood glucose >3 times/day (P = 0.004). Fasting ability was not significantly higher in patients with diabetes without comorbidities (P = 0.973), diabetes complications (P = 0.900), and nor having longer duration of diabetes (P = 0.129) [Table 2].
|Table 2: Comparison between patients who were able to fast and not able to fast (n=367)|
Click here to view
Out of 367 patients with diabetes, 326 (88.8%) participants had the ability to fast and were included in comparing patients experience in Ramadan 2019 and Ramadan 2020. The results showed no significant differences in: patient ability to consult a doctor, the frequency of self-monitoring of blood sugar, or stopping fasting due to hypoglycemia ( P = 0.640, 1.000, 1.000, and 0.701, respectively). Having hypoglycemia <70 mg/dl among patients fasting Ramadan 2020 was less than Ramadan 2019, and the difference was significant, P = 0.017 [Table 3].
|Table 3: Comparing characteristics of patients with diabetes fasting Ramadan 2019/1440 and 2020/1441 (n=326)|
Click here to view
Based on the type of treatments, patients on noninsulin treatment had significantly fewer hypoglycemia episodes during Ramadan 2020 than Ramadan 2019 (P = 0.006). Patients on insulin treatment had fewer hypoglycemia episodes during Ramadan 2020 than Ramadan 2019, but the difference was not significant (P = 0.405) [Figure 1].
|Figure 1: Hypoglycemia during fasting Ramadan 2019 and 2020 among patients with diabetes (n = 326)|
Click here to view
Predictors of hypoglycemia during fasting Ramadan 2020 were the younger age group (14–30 years and 31–45 years), longer duration of diabetes (more than 10 years), and insulin management.
The probability of hypoglycemia during fasting Ramadan 2020 was higher among younger age groups 14–30 years (odds ratio [OR] 7.24, 95% confidence interval [CI] 1.72–30.39), patients aged 31–45 years (OR 7.18, 95% CI 1.97–26.19), patients with longer duration of diabetes (more than 10 years) (OR 2.30, 95% CI 1.01–5.26), and patients on insulin (OR 14.14, 95% CI 1.72–30.39).
| Discussion|| |
In this cross-sectional study, patients with diabetes who had been included did not have increased hypoglycemia episodes while fasting in the month of Ramadan 2020 compared to that in 2019. However, the timing of lockdown concurs with the recommended time to provide diabetic patients with targeted education. Studies have shown that such a practice, whether in a group session or one to one, can reduce the risk of hypoglycemia and indeed other possible complications. The study also shows no negative impact of lockdown on patients' ability to visit their doctors. Most of the patients during this period had been contacted by their healthcare providers through virtual clinics. Telemedicine is a useful adjunct to reduce the risk of hypoglycemia in some studies.
The rate of hypoglycemia was higher among patients treated with insulin and/or oral hypoglycemic agents more than patients treated with diet alone [Table 4]. It is known that hypoglycemia episodes are higher among patients treated with insulin therapy, mainly Type 1 diabetes. Although fasting in Ramadan for Type 1 diabetes was feasible, patients are advised about the importance of adequate glycemic control before Ramadan and frequent glucose monitoring during fasting., In our study results, hypoglycemia episodes during the lockdown in 2020 were not inferior to that in Ramadan 2019 among patients treated with insulin therapy [Figure 1].
|Table 4: Logistic regression for predictors of hypoglycemia during fasting Ramadan 2020 (n=326)|
Click here to view
Predictors of hypoglycemia show higher episodes in the younger age group, patients with longer than 10 years of diabetes history, and patients treated with insulin and/or oral hypoglycemic agents. Patients with diabetes are known to have a significant increase in hypoglycemia during fasting, which is higher in patients treated with sulfonylurea and/or insulin and in patients with long duration of diabetes.,
Although hypoglycemia is most common among older patients with multiple or advanced comorbidities, our study's results did not show a significant increase among this group of patients [Table 4]. Although it could be related to the method of data collection, this result could be an indirect indicator of telemedicine's value in providing pre-Ramadan education to those groups of patients. Our results showed that the presence or absence of comorbidities did not affect the decision and capability for patients to fast during the month of Ramadan [Table 2], in a published systematic review of randomized control trials there was minimal diversity in the published results for the safety of fasting among patients with a high risk of fasting.
| Conclusions|| |
There is no negative effect of lockdown on the Ramadan fasting experience of patients with diabetes. Indeed, patients had even less episode of complications such as hypoglycemia during their fasting. Telemedicine services may have improved our study's clinical outcome during the pandemic, and implementing telemedicine beyond the pandemic should be encouraged.
All authors contributed to the conception of the study, data acquisition and analysis, and drafting and revision of the manuscript. They all approved its final versions.
Compliance with ethical principles
The institutional review board approved the Qatif Central Hospital's study, Qatif, KSA (QCH-SREC0205/2020). The patient provided consent for participation, and all data were reported anonymously.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
Data are available by reasonable requests to the corresponding author.
| References|| |
Cucinotta D, Vanelli M. WHO Declares COVID-19 a Pandemic. Acta Biomed 2020;91:157-60.
Atalan A. Is the lockdown important to prevent the COVID-19 pandemic? Effects on psychology, environment and economy-perspective. Ann Med Surg (Lond) 2020;56:38-42.
Monaghesh E, Hajizadeh A. The role of telehealth during COVID-19 outbreak: A systematic review based on current evidence. BMC Public Health 2020;20:1193.
Simple P, Oswald S, Schwarz PE, Harst L. Mapping the evidence on the effectiveness of telemedicine interventions in diabetes, dyslipidemia, and hypertension: An umbrella review of systematic reviews and meta-analyses. J Med Internet Res 2020;22:e16791.
Meo S. COVID-19 pandemic: Saudi Arabia's role at national and international levels. J Diabetes Sci Technol 2020;14:758-9.
AlKhaldi YM, AlKhaldi AY, AlQahtani AS, Al-Shahrani BS, Meshawi EA, Albishri BM. Incidence of hypoglycemia and its risk factors among people with diabetes during Ramadan in Abha city, Aseer Region, KSA. J Family Med Prim Care 2019;8:2793-8.
] [Full text]
Mohamed OM, Hassanein M, Syeed A, Khan FB, Al Tunaiji M, Al Mazrouei S, et al
. Impact of pre-Ramadan intervention program on diabetic patients (PRINTED 1): A randomised controlled trial in a family medicine clinic Abu Dhabi. 2019;2019:93594.
Tourkmani AM, Hassali MA, Alharbi TJ, Alkhashan HI, Alobikan AH, Bakhiet AH, et al
. Impact of Ramadan focused education program on hypoglycemic risk and metabolic control for patients with Type 2 diabetes. Patient Prefer Adherence 2016;10:1709-17.
Hassanein M. Ramadan focused on diabetes education; a much-needed approach. J Pak Med Assoc 2015;65 Suppl 5:S76-8.
Lee JY, Wong CP, Tan CS, Nasir NH, Lee SW. Telemonitoring in fasting individuals with Type 2 Diabetes Mellitus during Ramadan: A prospective, randomized controlled study. Sci Rep 2017;7:10119.
Alabbood MH, Ho KW, Simons MR. The effect of Ramadan fasting on glycaemic control in insulin-dependent diabetic patients: A literature review. Diabetes Metab Syndr 2017;11:83-7.
UK Hypoglycaemia Study Group. Risk of hypoglycaemia in Types 1 and 2 diabetes: Effects of treatment modalities and their duration. Diabetologia 2007;50:1140-7.
Salti I, Bénard E, Detournay B, Bianchi-Biscay M, Le Brigand C, Voinet C, et al
. 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 2004;27:2306-11.
Silbert R, Salcido-Montenegro A, Rodriguez-Gutierrez R, Katabi A, McCoy RG. Hypoglycemia among patients with Type 2 diabetes: Epidemiology, risk factors, and prevention strategies. Curr Diab Rep 2018;18:53.
Rashid F, Abdelgadir E, Bashier A. A systematic review of the safety of Ramadan fasting in high-risk patients with diabetes. Diabetes Res Clin Pract 2020;164:108161.
[Table 1], [Table 2], [Table 3], [Table 4]