Keywords
COVID-19 - hypoglycemia - insulin - lockdown - pandemics - telemedicine
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,[[1]] COVID-19 cases and daily deaths have led to worldwide lockdown and restrictions
for social distancing as a measure to limit virus spread.[[2]] 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.[[3]],[[4]] 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.[[5]] 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.[[6]] 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.[[7]],[[8]] 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.[[9]] 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]].
Table 1: Participants characteristics (n=367)
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)
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)
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)
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.[[10]] 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.[[11]]
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.[[12]],[[13]] 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)
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.[[14]],[[15]]
Although hypoglycemia is most common among older patients with multiple or advanced
comorbidities,[[15]] 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.[[16]]
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.
Authors' contribution
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.
Data availability
Data are available by reasonable requests to the corresponding author.
