Management of diabetes during ramadan fasting: A comprehensive survey of physicians’ knowledge, attitudes, and practices
Authors: Beshyah Salem , Farooqi Muhammad , Farghaly Mohamed , Abusnana Salah , Al Kaabi Juma , Benbarka Mahmoud ,   The MENA Endocrine Research Group
Published: July 2017

Background: Physicians play a role in informing patients’ choices to fast or not and also in education and support of those diabetic patients who choose to observe the Ramadan fast. Objectives: To ascertain physicians’ knowledge, attitudes, and practices regarding practical management of diabetes during Ramadan. Subjects and Methods: A cross-sectional Internet-based survey of a convenience sample of physicians, mostly practicing in UAE, was included. The survey questionnaire was developed de novo to address the objectives of this exercise. Responses were collected completely anonymously and were summarized using descriptive statistics. We report here the responses from 236 physicians who submitted adequately completed questionnaires. Results: General management knowledge varied widely. Over 90% recognized the importance of Ramadan-focused education, 75.1% valued the importance of glycemic control at night time, and 71.2% were aware of the exemption of T1DM. 69.0% were familiar with the time of highest risk of hypoglycemia, and 62.0% knew the rulings regarding exemption of pregnant women with diabetes. There was an awareness of the advantages of DDP-IV inhibitors over sulphonylureas, but many thought that all sulphonylureas carry the same hypoglycemic risk potential. Many physicians would maintain metformin and pioglitazone in the same daily doses and use SGLT2 inhibitors carefully in certain groups. Nearly two-thirds of respondents were aware of the traditional adjustments of doses and timing of sulphonylureas. Most (>90%) of respondents recognized the importance of prompt management of hypoglycemia, the need and permission to monitor blood glucose during the day and that potential for the use of GLP1 therapy is supported by experimental evidence. About three quarters recognized the usual practice of reversing the insulin doses when premixed insulin between day and night but only thirds recognized the possible need to reduce basal insulin to avoid hypoglycemia. Attitude: Perceived level of self-confidence, 71% of the respondents stated that they are fully confident or somewhat confident in the management of diabetes during Ramadan. There was a wide variation in recognition of relevant concerns and risks associated with fasting during Ramadan in people with diabetes. Hypoglycemia was the most highly recognized risk (96%) followed by dehydration (85%). About two-thirds of respondents’ associated increased risk of hyperglycemia and diabetic ketoacidosis with fasting. Less than half of respondents recognized the increased risks in pregnancy and of thromboembolic disease. Forty- one percent of respondents followed the ADA workshop of 2005 and its updates. Its risk scale was thought to be the most practical by 34% of respondents. Risk stratification practices were stated to be undertaken consistently, often or occasionally (80%, 15%, and 5% of respondents respectively). 78% confirmed formal stratification using one of the published guidelines. Clinical management practices during the previous month of Ramadan, a total responded positively in high proportions to almost all the questions with no particular differences between the issues nor between the care settings and facilities. Younger doctors were not especially competent as their more senior colleagues. Conclusions: Physicians demonstrated variable levels of knowledge about care of patients with diabetes during Ramadan. Reported self-reported competence was not matched by actual knowledge and treatment practices. Continued education, mentoring and support schemes are needed with regular assessments before Ramadan fast on an annual basis.