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Hypoglycemia poses danger for women with gestational diabetes observing Ramadan fast

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December 7, 2017

Among women with gestational diabetes, those who opted to fast during the Muslim holy month of Ramadan experienced lower mean glucose levels during the fasting period but higher rates of hypoglycemia than those who did not fast, according to an analysis published in BMJ Open Diabetes Research & Care.

“While Ramadan fasting is obligatory to all healthy adult Muslims, exemptions exist for many, including women during pregnancy as well as for those with medical illness,” Bachar O. Afandi, MD, FACE, of the division of endocrinology at Tawam Hospital in Al Ain, United Arab Emirates, and colleagues wrote. “Nevertheless, many studies have shown that the majority of healthy pregnant women opt to fast, despite the burden of fasting while pregnant.”

In a prospective, observational study, Afandi and colleagues analyzed data from 32 pregnant women with diagnosed gestational diabetes treated with diet plus metformin therapy, who chose to fast during the lunar month of Ramadan 2017 (May 26 through the evening of June 24). Before Ramadan, a multidisciplinary team, including diabetes educators and nutritionists, counseled all patients. Patients consented to wear a continuous glucose monitoring device (iPro2, Medtronic) for a minimum of 3 days, and they were asked to check blood glucose levels a minimum of three times per day, as patients were masked to CGM data. Hyperglycemia was defined as a glucose level of at least 140 mg/dL; hypoglycemia was defined as a blood glucose level of 70 mg/dL or less. Severity of hypoglycemia was classified as mild (60 to 69 mg/dL), moderate (50 to 59 mg/dL) or severe (< 50 mg/dL).

Within the cohort, mean age was 33 years; mean prepregnancy BMI was 29.5 kg/m². The cohort was divided into three groups: diet only, monitored before Ramadan (group 1; n = 10); diet only, monitored during Ramadan fasting (group 2; n = 13); and diet plus metformin 500 mg twice per day, monitored during Ramadan fasting (group 3; n = 9). Patients practiced self-monitored blood glucose on average 3.4 times per day. All patients completed their fast with no adverse events.

In groups 1, 2 and 3, mean glucose levels were 116 mg/dL, 106 mg/dL and 99 mg/dL, respectively, according to CGM data. Patients in the pre-Ramadan group (group 1) had the highest incidence of hyperglycemia at 32% and no incidence of hypoglycemia, whereas patients in the diet-plus-metformin group (group 3) had the highest rate of hypoglycemia at 78%, the highest rate of normoglycemia (mean time-in-range, 90.2%) and the lowest rate of hyperglycemia (5%).

“Our data indicate that glucose levels were better in those women with [gestational diabetes] fasting in Ramadan than pre-Ramadan whether they were treated with diet plus metformin or diet only,” the researchers wrote. “Indeed, the average difference between the pre-Ramadan and during Ramadan glucose level of group 3 who were treated with diet and metformin was over 17 mg/dL. Furthermore, this group had the highest rate of normoglycemia in the study.”

The researchers noted that the findings were similar to what was observed previously in a study from Saudi Arabia, where it was noted that women with gestational diabetes who fasted during Ramadan had a better glycemic control.

“Nevertheless, in our opinion, women with [gestational diabetes] should be advised against fasting until further studies on benefits and risks are conducted,” the researchers wrote.

The researchers additionally highlighted that the rates of severe hypoglycemia were markedly higher in group 2 and group 3 (23 and four episodes, respectively), compared with the nonfasting group, which had no severe hypoglycemia episodes.

“It is noteworthy that the hypoglycemic episodes detected during our study were all asymptomatic, and the implications of this should be further explored,” the researchers wrote. – by Regina Schaffer

Disclosures: The authors report no relevant financial disclosures.