diabetes research and clinical practice 172 (2021) 108530

Contents available at ScienceDirect

Diabetes Research
and Clinical Practice
journal homepage: www.elsevier.com/locat e/dia bre s

Review

Ramadan-focused nutrition therapy for people with

diabetes: A narrative review

Barakatun-Nisak Mohd Yusof a,b,c,*, Nor Farahain Yahya a, Farah Yasmin Hasbullah a,
Wan Zul Haikal Hafiz Wan Zukiman d, Azrina Azlan a,b, Rachel Liu Xin Yi e,
Agnieszka Marczewska f, Osama Hamdy g
a
Department of Nutrition and Dietetics, Faculty of Medicine and Health Sciences, Universiti Putra Malaysia, 43400 Serdang, Selangor,
Malaysia
b
Research Centre of Excellent for Nutrition and Noncommunicable Chronic Diseases, Faculty of Medicine and Health Sciences, Universiti Putra
Malaysia, 43400 Serdang, Selangor, Malaysia
c
Institute for Social Science Studies, Universiti Putra Malaysia, 43400 Serdang, Selangor, Malaysia
d
Department of Medicine, Faculty of Medicine and Health Sciences, Universiti Putra Malaysia, 43400 Serdang, Selangor, Malaysia
e
Nestlé Health Science, Petaling Jaya 47810, Malaysia
f
Nestlé Health Science, 1800 Vevey, Switzerland
g
Joslin Diabetes Centre, Harvard Medical School, MA 02215, USA

A R T I C L E I N F O A B S T R A C T

Article history: Aims: This narrative review aimed to synthesize the evidence on the effects of Ramadan-
Received 12 June 2020 focused nutrition therapy for people with diabetes.
Accepted 26 October 2020 Methods: We searched MEDLINE (via PubMed) and Science Direct databases for articles that
Available online 4 November 2020 included the component of nutrition for adult patients with type 2 diabetes (T2D), pub-
lished in English between 2010 and 2020.
Results: Fourteen studies met the criteria. Eight of 14 studies had an intervention with a
Keywords:
control arm. In comparison to the control group, all studies (n = 8) showed a reduction in
Ramadan
hypoglycemic events. However, only half of these studies (n = 4) had shown at least one
Fasting
positive clinical outcome. Features of nutrition therapy that appeared to have favorable
Diabetes
clinical outcomes include individualized caloric prescription; distributing carbohydrates
Nutrition therapy
equally between Suhoor, Iftar and snacks; providing meal plans; adjusting food intake to suit
Ramadan; and incorporating diabetes-specific formula as part of Suhoor or snack.
Conclusions: The review provides evidence for the effectiveness of Ramadan-focused nutri-
tion therapy among people with T2D and identifies key features of nutrition therapy that
may provide favourable clinical outcomes. Additional data on dietary quality and adequacy
during Ramadan fasting warrants further studies.
Ó 2020 Elsevier B.V. All rights reserved.

* Corresponding author at: Department of Nutrition and Dietetics, Faculty of Medicine and Health Sciences, Universiti Putra Malaysia,
43400 Serdang, Selangor, Malaysia.
E-mail address: [email protected] (B.-N. Mohd Yusof).
https://doi.org/10.1016/j.diabres.2020.108530
0168-8227/Ó 2020 Elsevier B.V. All rights reserved.
2 diabetes research and clinical practice 172 (2021) 108530

Contents

1. Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
2. Methods . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
2.1. Study selection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
2.2. Literature search . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
2.3. Data extraction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
3. Results . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
3.1. Description of studies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
3.2. Intervention studies with a comparison group. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
3.3. Intervention studies without a comparison group . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
3.4. Key features of the Ramadan-focused nutrition therapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
3.5. Analyses of key features . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
4. Discussion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
5. Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
Funding . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
Author contributions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
Declaration of Competing Interest. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13

1. Introduction

Diabetes is a significant public health problem worldwide. ketoacidosis [4,5]. Moreover, long hours of abstaining from
Approximately 463 million adults are living with diabetes, foods during the daytime may lead to over-eating with inap-
representing a prevalence of 9.3% worldwide [1]. The preva- propriate food choices at night, which usually comprise of
lence is expected to escalate further to 10.9% (700 million huge amounts of food rich in carbohydrates and sugary
adults) by 2045 as consequences of increased obesity, seden- drinks [6].
tary lifestyle, and aging population [1]. T2D accounts for Although the professional diabetes guidelines emphasize
approximately 90% of all diabetes cases worldwide [1]. The the importance of MNT during Ramadan, yet, the best nutri-
prevalence of people with type 2 diabetes (T2D) is increasing tional approach for Ramadan fasting remains challenging
in most countries and even higher in several large Muslim- due to cultural and regional differences [2]. Most of the previ-
majority countries (including Indonesia, Egypt and Bangla- ous reviews on Ramadan fasting in diabetes had focused on
desh), with approximately 150 million Muslims living with safety of Ramadan fasting [7,8], the role of drug therapy [9–
diabetes worldwide [2]. 14], diabetes management recommendations [15–18], other
Fasting during the holy month of Ramadan, one of the five medical treatments [6,19–21], health outcomes [22–24], or
pillars of Islam, is an obligatory duty for all healthy adult Mus- the impact of Ramadan-focused education with limited con-
lims. Muslims must refrain from eating, drinking, engaging in tents on nutrition therapy [12,25]. The meta-analysis by Gad
sexual activities, smoking, and the use of oral medications et al. identifies that Ramadan-focused education improved
between dawn and sunset. Therefore, Ramadan has a major glycemic control and LDL-cholesterol but increased weight
impact on the management of diabetes in the Muslim popu- and triglycerides levels with no data reporting on the dietary
lation. Although people with diabetes can be exempted from intake outcomes [25].
Ramadan fasting, many of them continue to fast. A large Therefore, this narrative review identifies and synthesizes
population-based study conducted in 13 countries estimated the evidence about the effects of Ramadan-focused nutrition
about 79% of Muslims with T2D would fast during Ramadan therapy for people with diabetes. We examine the key fea-
[3], suggesting the critical need to understand the implica- tures of the nutrition therapy component that may provide
tions of Ramadan fasting for people with diabetes. favourable clinical outcomes. The findings would help health-
Medical nutrition therapy (MNT) is a fundamental aspect care professionals to identify the most successful nutritional
of diabetes management, becoming even more critical during approach for individuals with T2D who wish to observe
Ramadan fasting. During Ramadan fasting, patients can con- Ramadan fasting.
sume meals during night-time with two main meals known
as Suhoor (served before dawn) and Iftar (served after sunset). 2. Methods
Thus, Ramadan incurs a significant change in dietary and life-
style patterns as compared with other times of the year with 2.1. Study selection
consequent changes in physiological processes [4,5]. During
prolonged fasting, insulin resistance or deficiency causes We included studies providing Ramadan-focused interven-
excessive glycogen breakdown leading to increased gluconeo- tion that included the component of nutrition therapy for
genesis and ketogenesis, thus resulting in hyperglycemia and adults with type 2 diabetes (T2D) and assessed at least one
 diabetes research and clinical practice 172 (2021) 108530 3

of the commonly measured clinical outcomes during Rama- described [27]. On the other hand, the other six studies eval-
dan. The outcomes include blood glucose, anthropometric uated the effect at pre-post effects using a prospective obser-
data, lipid profile, dietary intake, safety data, and additional vational study without a control arm [28,31,33,35,37,38]
outcomes such as quality of life. To be included, studies had (Table 2).
to be conducted in humans, mainly among patients with In general, the number of participants ranged from 12 to
T2D who were observing Ramadan fasting, and provide a 262. The studies were mainly conducted in Arab speaking
Ramadan-focused education with nutritional therapy as a countries (n = 7) including three from United Arab Emirates
highlight. Studies were excluded if fasting was performed (UAE) [27,37,38], two from Egypt [33,36], one from Saudi Arabia
outside Ramadan, such as intermittent fasting; did not spec- [32] and one from Tunisia [34]. Five studies were conducted in
ify any nutrition plan component; or studied in individuals South East Asia [29,30,31,35,39], including one from Malaysia
with gestational or type 1 diabetes. [39], two from Thailand [29,30] and two from Singapore
[31,35]. The remaining two studies were performed in Pak-
2.2. Literature search istan [28] and United Kingdom [26], respectively. Study dura-
tion varied between 4 and 16 weeks, with at least 2 to 4
We searched for articles published in English between 2010 study visits performed throughout the study period.
and 2020; using two electronic databases, MEDLINE (for
PubMed) and Science Direct (for Elsevier), based on the fol- 3.2. Intervention studies with a comparison group
lowing search terms and their combinations: ‘‘diabetes”
AND ‘‘education” OR ‘‘intervention” OR ‘‘therapy” OR ‘‘plan” In studies with a control group (Table 1), the number of partic-
AND ‘‘Ramadan fasting”. The reference lists of review articles ipants ranged from 54 to 262, with a total of 1094 participants
and original publications were also screened for potentially across the studies. Half of the studies (n = 4) were conducted
relevant studies. in Arab speaking countries (Egypt, Saudi Arabia, Tunisia, and
UAE) [27,32,34,36]; three studies in South East Asia (Malaysia
2.3. Data extraction and Thailand) [29,30,39] and one in the United Kingdom [26]
(Table 1).
Data extraction of relevant study information for articles All eight studies included adult patients with T2D, with
meeting inclusion criteria was performed independently by most of them in their 50 s and higher proportion of female
two reviewers (BNMY and FAY). Disagreements were resolved participants (62%). Participants had been diagnosed with
through discussion. The extracted data include information T2D for at least 5 to 13 years, and had a non-optimal HbA1c
on study location, study design, participant characteristics, level at baseline (>6.5%). The diabetes therapy included a
number of participants, study duration, study visits, features combination of either oral anti-diabetes agents (OAD) with
of Ramadan-focused nutrition therapy, other components of insulin (n = 4) [30,32,34,36] or OAD alone (n = 2) [26,39]. The
Ramadan-focused education, outcome measures (between other two studies did not report diabetes medication [27,29].
and within-group effects), and main findings. We scrutinized Study duration varied between 8 and 12 weeks, with at least
study limitations to identify the gaps for future rectifications 2 to 4 study visits. Outcome measures included blood glucose,
and recommendations. anthropometric data, lipid profiles, safety data, and dietary
intake, as well as other parameters such as quality of life,
3. Results hypoglycemia occurrence, hospitalization, and awareness
scores. All outcomes were collected 2 to 4 weeks before and
The search strategy identified a total of 139 articles published after Ramadan with one study collected the HbA1c data after
on Ramadan-focused education with nutrition components a year of Ramadan [32].
mentioned and highlighted in the study. After removing The Ramadan-focused nutrition therapy improved glyce-
duplicates, screening the title and abstract, and assessing mic control (n = 4) [30,32,36,39], body weight (n = 2) [32,36]
the full text, we excluded 125 articles. After exclusion, we in particular among patients with overweight (n = 1) [34],
finally included a total of 14 studies in this narrative review and lipid profile (n = 3) [32,36,39]. All studies (n = 8) showed
[26–39]. a reduction in hypoglycemia rates or frequencies
[26,27,29,30,32,34,36,39]. Despite delivering nutrition inter-
3.1. Description of studies vention, only two studies assessed changes in dietary intake.
With nutrition therapy, patients in the intervention group
Eight studies had a prospective interventional design with a were able to reduce carbohydrates [39] and sugar intake [29],
control arm. Five of them were non-randomized whereas protein and fibre intake increased only after Rama-
[27,32,34,36,39] with one study considering patient’s prefer- dan period [39].
ence for the allocation to study arm [39]. The remaining stud-
ies were quasi-experimental [29] and retrospective analyses 3.3. Intervention studies without a comparison group
[26], respectively. Only one study randomly assigned patients
to either an intervention or control arm [30] (Table 1). The There was a total of six studies with the sample size ranging
control group was provided either a standard care of nutrition from 12 to 67 with a total of 170 participants in all studies
therapy [30,32,36,39], continued current regimen with physi- [28,31,33,35,37,38]. Half of them were conducted in Arab
cians [29,34], received no education [26] or was not properly speaking countries (UAE and Egypt) [33,37,38], followed by
South East Asia (Singapore) [31,35] and South Asia (Pakistan)
 4
Table 1 – Characteristics of studies with a comparison group.
No Author, year (Country) Study Characteristics Features of Ramadan-focused Nutrition Plan Intervention vs Comparison Within Group Main Findings and
group Limitations
Intervention Group Comparison Group Intervention Group Comparison Group

1 Mohd. Yusof et al. 2020 Design: Non- Provided a structured Provided a standard care Glucose outcomes Glucose outcomes: Glucose outcomes: Summary:
[39] randomized, a parallel, Ramadan nutrition with the adjustment of
FBG (p < 0.05)
HbA1c (-0.72%)***
HbA1c (-0.35%)
The structured NT
(Malaysia) prospective intervention planThe structured usual food intake suit to
HbA1c (NS)
FBG (-0.90 mmol/L)***-
FBG (+0.15 mmol/L) regimen with DSF
studyDuration:~ 8- Ramadan Nutrition plan Ramadan fastingProvide Anthropometric: Anthropometric: for Ramadan is a

SMBG (p < 0.05)Anthropo-
weeksStudy visits: 3 include; pre-Ramadan education: feasible and benefi-
metric
Weight (-1.60 kg)***
Weight (-1.57 kg)***

2-weeks pre-
individualized calo-
NoOthers: cial program for

Weight (NS)
BMI (-0.64 kg/m2)***Lipid
BMI (0.60 kg/m2)***Lipid
Ramadan ric and macronutri-
Perform self-moni- T2D. It showed an
ent prescriptions
BMI (NS)Lipid profile profile (mmol/L): profile (mmol/L):

4 weeks during toring blood glucose improvement in
(mmol/L)
TC (-0.10)***
TC (-0.20) clinical outcomes
Ramadan
equal distribution
for carbohydrate
TC (NS)
TG (-0.21)***
TG (0.20) and QoL.Limitations:

2–4 weeks after

diabetes research and clinical practice

RamadanN: 64 between Sahuur
TG (p < 0.05)
LDL (-0.11)
LDL (-0.34)
Non-randomized
and iftar or snacks approach
(I = 41; C = 23)
LDL (NS)
HDL (0.16)***Other out-
HDL (0.10)**Other out-
Age: 50 s if necessary comes: comes:
Patients’ selected

HDL (p > 0.05)Dietary
% Male: 51%
consumption of dia-
QoL (Improved)***
QoL (NS) their own study arm
intake improvement
Diabetes Treatment: betes-specific for-

Yes (;CHO, "protein, "fi-
OADs mula as a Sahuur or
bre)Safety:
Diabetes duration: ~ snack

Hypoglycemic rates (NS)
5 years
Provided the Rama-
Baseline HbA1c:
Fequency of hypo-
dan toolkits (Rama-
8.0% glycemia (reduced num-
dan flip chart, 14-
Intervention provi- ber, p < 0.05)Other
day menu plan,
der: Doctor and outcomes:
Ramadan Nutrition
dietitian Plate, and Festive
QoL (NS)
season nutrition
planProvided pre-
Ramadan education:

YesOther topics for
Ramadan-focused
intervention:

Awareness on hypo-
glycemia, hyper-

172 (2021) 108530

glycemia and
hydration status

Importance of self-
monitoring blood
glucose
2. El Toony et al. 2018 [36] Design: A prospective Provided advice to adjust Standard careProvided Glucose outcomes: Glucose outcomes: Glucose outcomes: Summary:
(Egypt) interventional usual food intake suit to pre-Ramadan education:
FBG (p < 0.05)
FBG (-3.04 mmol/L)
FBG (-3.65 mmol/L)***
The intervention
studyDuration: ~ Ramadan
No
HbA1c (p < 0.001)Anthro-
HbA1c (-0.3%)Anthropo-
HbA1c (-0.77%)***Anthro- reduced hypogly-
12 weeksStudy visits: 3 fastingProvided pre- pometric: metric: pometric: caemic risk, other

2–3 weeks pre- Ramadan education:

Weight (p < 0.01)
Weight (-0.3 kg)*
Weight (0.05 kg) acute complications,
Ramadan,
YesOther topics for LDLc, and improved
Ramadan-focused

BMI (NS)Lipid profile
BMI (-0.28 kg/m2)*Lipid
BMI (0.11 kg/m2)Lipid

4 weeks during HDL
(mmol/L): profile (mmol/l): profile (mmol/L):
Ramadan intervention:
The intervention is

Hypoglycemia

TC (" p < 0.001)
TC (-0.30)***
TC (-0.14)

4 weeks after Rama- beneficial for high
awareness and
TG (NS)
TG (-0.05)*
TG (+0.11) and very high risk
danN = 230
(I = 120; C = 120) when to break the
LDL (p < 0.001)
LDL (-0.16)
LDL (0.08) patientsLimitations:
fast during Ramadan
Non-randomized
Age: 50 s
HDL (p > 0.001)Dietary
HDL (+0.10)***Other out-
HDL (+0.13)***Other out-
% Male = 25%
Physical activity intake improvement: comes: comes: approaches
Diabetes Treatment:
Self-monitoring
Not assessedSafety:^
No episode of hospitaliza-
4 needed hospitalization
Baseline characteris-
Insulin and OADs blood glucose
Frequency of daily fasting tion and no DKA and 1 developed DKA tics were not compa-
Diabetes duration: ~ (70% vs. 50%) rable – more
8 years participants in inter-

Hypoglycemic rates (4.1%
Baseline HbA1c: vention were high
vs. 19.5%)^ not statistical
8.7% risk.
test was reportedOther
outcomes:

Not assessed
Table 1 – (continued)
No Author, year (Country) Study Characteristics Features of Ramadan-focused Nutrition Plan Intervention vs Comparison Within Group Main Findings and
group Limitations
Intervention Group Comparison Group Intervention Group Comparison Group

3. Jamoussi et al. 2017 [34] Design: A prospective Provided advice on No nutrition education. Glucose outcomes: Glucose outcomes: ^ Glucose outcomes: ^ Summary:
Tunisia interventional study balanced food intake Continued current
HbA1c (NS)Anthropomet-
HbA1c (-0.27%)Anthropo-
HbA1c (No change)
The intervention
Duration: ~8 weeks (quantity and quality) by treatment provided by a ric: metric: ^ Anthropometric^ improved body
Study visits: 2 limiting fatty, fried food physicianProvided pre-
Weight (NS)
Weight (-1.05 kg)
Weight (-0.58 kg) weight among over-

1–2 weeks pre- and product with Ramadan education:

BMI – normal weight (NS)
BMI – normal (+0.55 kg)
BMI – normal (-0.60 kg) weight participants.
Ramadan, glycemic indexProvided
No
No differences in
pre-Ramadan education:
BMI Overweight (p < 0.05)
BMI – overweight(-1.24 kg)
BMI – overweight(-0.20 kg)

2 weeks after Rama- most parameters

YesOther topics for
BMI – obese (NS)Lipid pro-
BMI- obese (-1.05 kg)Lipid
BMI- obese (-0.95 kg)Lipid
danN = 54 could be related with
Ramadan-focused file: profile(mmol/L): ^ profile (mmol/L): ^
(I = 26; C = 28) lack of monitoring
intervention:
TC (NS)
TC (-0.13)
TC (-0.12)
Age: 50s during Ramadan.

diabetes research and clinical practice

% Male = 52%
Hypoglycemia and
TG (NS)
TG (-0.05)
TG (+0.01) Limitations:
Diabetes Treatment: hyperglycemia
LDL (-0.14)
LDL (-0.05)
Non-randomized

LDL (NS)
OADs awareness and approaches

HDL (NS)Dietary intake
HDL (Male + 0.07;
HDL (Male + 0.02;
Diabetes duration: ~ strategies to deal
improvement: Female + 0.11)^ no statis- Female + 0.04)^ no statis-
5 years with these issues

Not assessedSafety:^ tical test was reported tical test was reported
Baseline HbA1c: NR
Dehydration
prevention
Frequency of daily fasting
(28.5 vs.25.5 days)

Hypoglycemic rates (2%
vs. 4%)Other outcomes:-
4. Tourkmani et al. 2016 Design: A non- Provided individualised Provided standard care Glucose outcomes: Glucose outcomes: Glucose outcomes: Summary:
[32] randomized, prospective Ramadan-focused based on ADA
HbA1c at post Ramadan
HbA1c (-1.27%)***Anthro-
HbA1c (-0.45%)***Anthro-
Ramadan educa-
Saudi Arabia interventional controlled dietary advice which guidelinesProvided pre- (p < 0.001) pometric: pometric: tional program
design include Ramadan education:
HbA1c at 12 weeks post
Weight (+1.22 kg)
Weight (-0.80 kg) reduced hypo-
Duration:
diet adjustment
No Ramadan (p < 0.01)
BMI (+0.56 kg/m2)Lipid
BMI (-1.21 kg/m2)**Lipid glycemic risk,
11 weeks + 12 month
preferred and non- Anthropometric: HbA1c, and LDLc.
profile(mmol/L): profile(mmol/L):
(follow up after

The intervention can
preferred food at Weight (p < 0.01)
TC (-0.27)***
TC (-0.10)
Ramadan) breaking the fast be recommended for

BMI (p < 0.01)Lipid profile:
TG (-0.09)*
TG (-0.11)
Study visits: 4 patients with

best time for the sec-
TC (NS)

2–3 weeks pre-
LDL (-0.13)***
LDL (+0.07) increased risk of
ond meal.Provided
Ramadan
TG (NS)
HDL (+0.09)***Other out-
HDL (+0.15)***Other out- hypoglycemia dur-
pre-Ramadan educa-

172 (2021) 108530

During Ramadan tion: LDL (p < 0.01) comes: comes: ing Ramadan fast-

4 weeks after
YesOther topics for
HDL (NS)Dietary intake
Hypoglycemic score
Hypoglycemic score ing.Limitations:
Ramadan Ramadan-focused improvement: (improved)*** (improved)***
Non-randomized
intervention:
Not assessedSafety data:^ approach

12 weeks after
RamadanN: 262
Sign and symptoms
Hypoglycemic score
Baseline characteris-
(I = 140; C = 122) of hypoglycemia (p < 0.001)Other out- tic were not compa-
Age: 50s and hyperglycemia comes: rable (high insulin
% Male: 37%
Importance of self-
Not assessed dose in intervention,
Diabetes Treatment: monitoring blood residency and job
Insulin + OADs glucose status)
Diabetes duration:
Physical activity
13 years

Care for diabetic foot
Baseline HbA1c:
9.9%
Management of
acute complications

Medication
adjustments

Provide post Rama-
dan education
related to adjust-
ment of medication

5
 6
Table 1 – (continued)
No Author, year (Country) Study Characteristics Features of Ramadan-focused Nutrition Plan Intervention vs Comparison Within Group Main Findings and
group Limitations
Intervention Group Comparison Group Intervention Group Comparison Group

5. Prataksitorn & Design: A pre and post Provided individualised Control (standard) or Glucose outcomes: Glucose outcomes: Glucose outcomes: Summary:
Singchungchai 2014 [30] experiment with a Ramadan-focused wait-list (none) group
HbA1c (p < 0.01)
HbA1c (-0.59%)***Anthro-
HbA1c (+0.13%)***Anthro- The differences in
Thailand randomized controlled dietary advice which
Fasting blood glucose pometric: pometric: glucose outcomes were
trailDuration: ~8– include (p < 0.05)Anthropometric:
BMI (-0.41 kg/m2)Lipid
BMI (-0.05 kg/m2)Lipid no more significant after
12 weeksStudy visits: 2
Meal plan-
BMI (NS)Lipid profile: profile(mmol/L): profile(mmol/L): controlling for baseline

2–4 weeks pre- ningProvider: Nurse
Not assessed
Not assessed characteristics

Not assessedDietary
Ramadan practitionerProvided
intake improvement:

1–2 week during pre-Ramadan educa-

Not assessedSafety data:
Ramadan tion: ^

YesOther topics for

2–4 weeks after
Less hypoOther out-

diabetes research and clinical practice

Ramadan-focused
RamadanN: 212 comes: ^
(I = 104; C = 108) intervention:

Increased awareness
Age: 60s
Hypoglycemia,
score of selfcare
% Male: 20% hyperglycemia and
Diabetes Treatment: diabetes
Insulin + OADs complications
Diabetes duration:
Physical activity
7.5
Medication
Baseline HbA1c: adjustment
9.4%
6. Susilparat et al. 2014 [29] Design: Quasi Provided specific health Provided with routine Glucose outcomes: Glucose outcomes: Glucose outcomes: Summary:
Thailand experimental education before health
FBG (NS)Anthropometric:
FBG (+0.9)*Anthropomet-
FBG (-0.2)Anthropomet-
Intervention caused
studyDuration: ~8 Ramadan. The nutrition educationProvided pre-
Weight (NS) ric: ric: positive behaviour.
weeksStudy visits: 2 component included Ramadan education:

BMI (NS)Lipid profile:
Weight (-0.51 kg)
Weight (-0.14 kg) Participants reduced

10 days pre- proper food choices
No
BMI (-0.2 kg/m2)Lipid pro-
BMI (-0.1 kg/m2)Lipid pro- intake of sugar.

Not assessedDietary
Ramadan during fasting. Proper
This health care ser-
intake improvement: file(mmol/L): file(mmol/L):

2 weeks after Rama- food choices mean: vice corroborated

Decreased food intake
Not assessed
Not assessed
danN: 90
Avoid sweetened with Islamic leaders,
(NS)
(I = 62; C = 28) and oily foods is useful and suit-

Increased fluid intake
Age: 50s
Eat at least 2 meals able for Thai Mus-
(NS)
% Male: 25% per day and do not lims with diabetes

Decreased sugar intake

172 (2021) 108530

Diabetes Treatment: skip Suhour. mellitus type 2.Limi-
Insulin + OADs (p < 0.01)Safety data: ^ tation:

Eat in moderation as
Diabetes duration:
Decreased hypoglycemia
Non-randomized
practiced by Prophet
Not reported symptomps (p < 0.01) approach
Muhammad
Baseline HbA1c: SAWProvided pre-
Hospitalization (NS)Other
8.8% Ramadan education: outcomes: ^

YesOther topics for
Decreased physical activ-
Ramadan-focused ity (NS)
intervention:
Decreased sleep duration

Provided Ramadan- (NS)
focused health edu-
Fasting duration (NS)
cation together with
Islamic leader.

Sign and symptoms
of hypoglycemia
and hyperglycemia

Management of
acute complications
and risk
assessments

Medication
adjustments
Table 1 – (continued)
No Author, year (Country) Study Characteristics Features of Ramadan-focused Nutrition Plan Intervention vs Comparison Within Group Main Findings and
group Limitations
Intervention Group Comparison Group Intervention Group Comparison Group

7. Mustafa et al. 2012 [27] Design: A non- Provided Ramadan- Not reported Glucose outcomes: Glucose outcomes: Not reported Summary:
United Arab Emirates randomized, prospective targeted education. The
Not reportedAnthropo-
HbA1c (-1.1%)** Targeted education for
interventional controlled nutrition component metric:
FBG (-2.83 mmol/L)** Ramadan improved
designDuration: was given via dietary
Not reportedLipid profile: hypoglycemic rates

Random blood glucose
~10 weeksStudy visits: 3 counselling but was not
Not reportedDietary during Ramadan.
(0 mmol/L)

1–2 week pre- explained in intake improvement: Limitations:
Ramadan detailProvided pre-
Fructosamine (-0.8 mmol/
Non-randomized

Not reportedOther out-
Ramadan education: L)*Anthropometric data: approaches

During Ramadan come: ^

YesOther topics for
Weight (+0.2 kg)Lipid pro-


4 weeks post Rama-
Number of not developed Included both type 1
Ramadan-focused file mmol/L:
hypoglycemia (93.8 vs and type 2 diabetes

diabetes research and clinical practice

danN: 71
intervention: 72.2)^ no statistical test
TC (0)
(I = 51; C = 13)
No comparison

Provided risk assess- was reported
TG (-0.29)* between interven-
Age: 50s
ments and medica- tion and controlled
% Male: 35%
tion adjustment
Diabetes Treatment:
The targeted educa-
Not reported
Multiple education tion components
Diabetes duration: sessions were not reported in
Not reported detail
Baseline HbA1c:
8.3%
8. Bravis et al. 2010 [26] Design: A retrospective Provided Ramadan- No education provided Glucose outcomes: Glucose outcomes: Glucose outcomes: Summary:
England analysesDuration: ~8– focused education.
Not reportedAnthropo-
HbAlc at 12 months(-
HbAlc at 12 months
Ramadan-focused
10 weeksStudy visits: 4 Nutrition components metric: 0.13%)Anthropometric: (+0.33%)Anthropometric: education mini-

2–4 weeks pre- included;
Not reportedLipid profile:
Weight (- 0.7 kg)***
Weight (+0.6 kg)*** mizes the risk of
Ramadan
Reminded that the
Not reportedDietary hypoglycaemic

During Ramadan diet during Ramadan intake improvement: events and prevents
is not differed from a
Not reportedOther out- weight gain during

4 weeks post
healthy come: this festive period
Ramadan

balanced diet
Number of hypoglycemia which potentially

12 months after the benefits metabolic

Encouraged slow (p < 0.001)
programN: 111 control.Limitations:
(I = 57; C = 54) energy-release food

Non-randomized
(such as wheat,

172 (2021) 108530

Age: 50s approaches
% Male: 57%
semolina, beans,

Retrospective
Diabetes Treatment: rice)
analyses
OAD
Minimizes food high
Diabetes duration:
Small population
in saturated fat
Not reported selection
(such as ghee,
Baseline HbA1c:
A selection bias, as

samosas and pako-
8.1% many of the patients
ras)Provided pre-
that participated in
Ramadan education:
the education pro-

YesOther topics for
gramme were self-
Ramadan-focused
selected, an attri-
intervention:
bute that may

Physical activity

predispose them to

Risk assessments
better glycaemic

Importance of self- control in the first
monitoring blood place,
glucose
with greater effort at

Managing maintaining their
complications weight throughout

Ramadan and avoid-
ing hypoglycaemic
events.

7
 8
Table 2 – Study characteristics of the studies without control group.

No Author, year Country Study characteristics Nutrition Intervention Findings (" increase, ; reduce, = Summary
no change)

1 Alawadi et al. 2019 [37] Design: Prospective Provided Ramadan-focused Glucose outcomes:
interventional study education based on SAFA—DAR
HbA1c (=)Anthropometric:
In patients with diabetes
United Arab Emirates Study duration: ~8–12 weeks program Nutrition components
Weight (=)Lipid profile: and CKD-stage 3 Rama-
Study Visits: 3 include,
Cholesterol (=) dan fasting under close

2–4 weeks pre-Ramadan
Dietary advice supervision and optimal

Triglyceride (=) diabetes care, was not

During Ramadan
Weight management associated with worsen-

LDL (=)Safety data: ing of HbA1c and renal

diabetes research and clinical practice

2–4 weeks post-RamadanN:
Calculation of calorie needs
No episode of hospitalization function.
19
Age: 60s
Meal planningProvided pre-
Hypoglycemia events (")
Patients had significantly
% Male: 58% Ramadan education: more frequent and pro-
Diabetes treatment: Insulin
YesOther topics for Ramadan-
longed hypoglycemic epi-
and OAD focused intervention: sodes during Ramadan.
Diabetes duration: NR
Safe fasting
Baseline HbA1c: 8%

When to break the fast during
Ramadan, Education on SMBG

Use of glucometer

Advice on dose adjustment for

anti-diabetic medications
2. Bashier et al. 2019 [38] Design: Prospective Provided Ramadan-focused Glucose outcomes:
United Arab Emirates interventional study education based on SAFA—DAR
HbA1c (; 0.3%)Anthropomet-
Patients treated with
Study duration: 8–12 weeks program Nutrition components ric data: insulin who had received

172 (2021) 108530

Study Visits: 3 include,
Weight (=)Lipid profile: Ramadan focused patient

2–4 weeks pre-Ramadan
Dietary advice education were safe to

Cholesterol (=)
fast as measured by bio-

During Ramadan
Weight management chemical, biometric and

Triglycerides (=)
FGM data.

2–4 weeks post-RamadanN:
Calculation of calorie needs

LDL (=)
67
None of the trials that
Age: 50s
Meal planningProvided pre- assessed patients with

HDL (=)Safety data:
% Male: 50% Ramadan education:
No episode of hospitalization T2D who were using insu-
Diabetes treatment: Insulin
YesOther topics for Ramadan- lin, compared the use of
only focused intervention:

Safe fasting
Hypoglycemia rate and the intensive versus basal
Diabetes duration: NR events (=)Other outcomes: insulin
Baseline HbA1c: 7.9%
Creatinine (=)

When to break the fast during
Ramadan, Education on SMBG

e-GFR (=)

Use of glucometer

Microalbuminuria (=)

Advice on dose adjustment for

Blood pressure (=)
anti-diabetic medications
Table 2 – (continued)

No Author, year Country Study characteristics Nutrition Intervention Findings (" increase, ; reduce, = Summary
no change)

3. Zainudin et al. 2018 [35] Design: Prospective Provided Ramadan-focused Glucose outcomes:
Singapore interventional study education and nutrition
HbA1c (; 0.3%)Anthropomet-
Muslims with diabetes
Study duration: ~12– components include, ric data: were able to self-manage
16 weeksStudy Visits: 4
Dietary adviceProvided pre-
Weight (; 0.7 kg) when fasting using tele-

4–6 weeks pre-Ramadan Ramadan education: monitoring support and

BMI (; 1.8 kg/m2)Lipid profile:

diabetes research and clinical practice

YesOther topics for Ramadan- intervention, with

2 weeks before Ramadan focused intervention:
LDL (" 0.05 mmol/L)
decreased complications

Medication adjustment
Triglyceride (" 0.35 mmol/L) during Ramadan com-

4 weeks during Ramadan
HDL (=)Other outcomes: pared with pre-Ramadan

General topic for diabetes
Renal (=)Safety data:

2–6 weeks post-RamadanN: education

Hypoglycemia and hyper-
29 (combination of Type 1 glycemia rate (;)
(n = 2) and Type 2 (n = 27) dia-
Tele-monitoring support
betes)
Age: 50s
Hypo and hyperglycemia
% Male: 24%
Diabetes treatment: Insulin
and OADs
Diabetes duration: Majority
(48.3%) > 20 years
Baseline HbA1c: 8.8%
4. Yeoh et al. 2015 [31] Design: Prospective Provided Ramadan-focused Glucose outcomes:

172 (2021) 108530

Singapore interventional study education and nutrition
HbA1c (; 0.6%)Anthropomet-
Ramadan fasting can be
Study duration: 6–8 weeks components include, ric data: practiced safely with prior
Study Visits: 2
Dietary advice
Weight (=) patient education and

2–4 weeks before Ramadan
BMI (;) medication adjustment.

Portion size estimation It also confers modest

Body fat mass (;)

End Ramadan weeks during benefits on metabolic pro-

Visceral adiposity (=)Dietary
RamadanN: 29
Daily meal and snack intake file and body composi-
intake:
Age: 50s estimationProvided pre-Rama-
Energy intake (=) tion, especially among
% Male: 52% dan education: females.

YesOther topics for Ramadan-
Carbohydrates intake (=)
Diabetes treatment: Insulin
focused intervention:
Protein intake (=)
and OADs

Education on SMBG and compli-
Fat intake (")Lipid profile:
Diabetes duration: Majority
cation of diabetes
Triglycerides (=)
(~40%) < 10 years
LDL (=)
Baseline HbA1c: 8.6%

Medication adjustment
HDL (=)Others:

Systolic (=)

Hypoglycemia
Diastolic (=)

9
 10
Table 2 – (continued)
No Author, year Country Study characteristics Nutrition Intervention Findings (" increase, ; reduce, = Summary
no change)

5. Eid et al. 2017 [33] Design: Prospective Provided Ramadan-focused Glucose outcomes:
Egypt interventional study education and nutrition
Random blood glucose (=)
Ramadan fasting is feasi-

diabetes research and clinical practice

Study duration: 12 weeks components include, ble for people with dia-
Study Visits: 12
Dietary advice
Fructosamine (; 19 umol/ betes who are on a

7 weeks (weekly visits) before L)’Safety data: multiple daily injection

Nutritional facts
Ramadan
Hypoglycemia events (;) insulin regimen and par-

Food pyramid
ticipate in the Ramadan

5 weeks during RamadanN:
Carbohydrate counting
focused education
14
Meal planningProvided pre- program.
Age: 30s Ramadan education:
% Male: 29%
YesOther topics for Ramadan-

The number of hypo-
Diabetes treatment: Insulin focused intervention:

Basic education on diabetes and glycemic events per
Diabetes duration:8.5 years month declined with the
diabetes complications
Baseline HbA1c: 6.7% attainment of DSME.

medication adjustment

Hypoglycemia awareness
6. Ahmedani et al. 2012 [28] Design: Prospective Provided Ramadan-focused Glucose outcomes:
interventional studyStudy education and nutrition
Random blood glucose (;)
With active glucose moni-
Pakistan duration: 4 weeksStudy Visits: 2 components include, Safety data: toring, alteration of drug

3 weeks before Ramadan
Dietary advice
No episode of hospitalization dosage and timing, diet-

172 (2021) 108530

Dietary modification
Hypoglycemia events (;) ary counselling and

2 weeks after RamadanN: 12
Lifestyle modificationProvided patient education, major-
Age: 60s pre-Ramadan education: ity of the patients did not
% Male: 53%
YesOther topics for Ramadan- have any serious acute
Diabetes treatment: focused intervention: complications of diabetes
Diet alone
Medication adjustment during Ramadan.
Diabetes duration: 2.7 years
Education on diabetes compli-
Baseline HbA1c: 6.2% cations

Education on SMBG

When to break fast

Hypoglycemia awareness
BMI, Body Mass Index; CKD, Chronic Kidney Disease; DKA, Diabetic Ketoacidosis; DSME, Diabetes Self-Management Education; FBG, Fasting Blood Glucose; HbA1c, Glycated Haemoglobin; HDL, High-
Density Lipoprotein; LDL, Low-Density Lipoprotein; OAD, Oral Anti Diabetic; SMBG, Self-Monitoring Blood Glucose; T1D, Type 1 Diabetes; T2D, Type 2 Diabetes.
 diabetes research and clinical practice 172 (2021) 108530 11

[28]. Most of these studies included adults with T2D, except

Glycemia Weight Lipid

for one study that combined them with type 1 diabetes [35].

NA
NA
NA
NA
NS
Patients’ age ranged from 30 s to 60 s, and half of the partic-

/
/

/
ipants were female (54%). They had been diagnosed with dia-
betes at least 3 years before the study, with their baseline

NA
NA
NS

NS

NS
NS
/

/
HbA1c ranging between 6.2 and 8.8%. The diabetes therapy
Nutrition Outcomes

included a combination of oral anti-diabetes agents (OAD)

with insulin (n = 3) [31,35,37], insulin alone (n = 2) [33,38] or

NA
NA
NS

NS
diet alone (n = 1) [28]. Study duration varied between 4 and
/
/

/
/
16 weeks with 2 to 4 study visits. One study conducted weekly
Dietitian
Provider

visits throughout 12 weeks for a total of 12 study visits [33].

Nurse
Outcome measures included glycemic control, anthropomet-
ric data, lipid profiles, dietary intake, and safety measures.
Patients were assessed at 2–7 weeks before Ramadan, and
non-preferred
Preferred vs.

2–6 weeks after Ramadan; one study collected the outcomes

just after the end of Ramadan. [33]
At the end of the observation period, glycemic levels (5
foods

studies) [28,31,33,35,38] and anthropometric data (2 studies)

p

[31,35] improved significantly, with three studies reporting

in moderation

reduced [28,33,35] or unchanged hypoglycemic rates or events

food intake

[38]. However, one study observed frequent and prolonged

Balanced
caloric needs meal plan specific formula intake to suit diet and

hypoglycemic episodes during Ramadan, that could have

been related to the high-risk profile of patients with diabetes
p

and stage 3 chronic kidney disease, who were closely moni-

tored using continuous glucose monitoring system (CGMS)
Adjust food

[37]. Dietary intake was assessed in one study, which identi-

Ramadan

fied reduced carbohydrate and increased dietary fats as com-

pared to baseline data [31].
p

p
Features of Ramadan-focused nutrition plan

3.4. Key features of the Ramadan-focused nutrition

Use diabetes-

therapy

The basis of the Ramadan-focused nutrition therapy features

is defined by the IDF-DAR guidelines or DAR-SAFA (Diabetes
p

and Ramadan Safe Fasting), which had been adopted by most

recent studies [37–39]. Most of these studies reported using
Set individual Provide

more than one topic for nutrition therapy components

[29,32,33,37–39] (topics were listed in Table 1). However, three
p

studies reported giving dietary advice without detailing the

nutrition therapy components [27,28,35].
All of the studies reported providing nutrition therapy for
at least 1–7 weeks before Ramadan (Table 1 and Table 2) vs.
none in the comparison group (Table 1). At pre-Ramadan,
Table 3 – Analysis of intervention components.

Eid et al. provided basic nutrition education for diabetes, such

p

as understanding nutritional facts, food pyramid, and carbo-

Prataksitorn & Singchungchai 2014 [30]

hydrate counting [33]. The Ramadan-focused nutrition ther-

apy mainly included dietary advice about adjusting food
intake [32,36], setting goals of individual caloric intake [37–
39], distributing carbohydrate equally between meals [39],
Mohd Yusof et al. 2020 [39]

Tourkmani et al. 2016 [32]

providing appropriate meal plan [30,33,37–39], correct food

Susilparat et al. 2014 [29]
Jamoussi et al. 2017 [34]
El Toony et al. 2018 [36]

Mustafa et al. 2012 [27]

choices [26,29,32], eating a balanced diet [34] and eating in

Bravis et al. 2010 [26]

moderation [29].
The recommended foods choice described in the publica-
tions included a reduction in fat and fried foods, choosing
foods with a low glycemic index, as well as avoiding sweet-
ened foods and beverages [26,29,34]. The Ramadan-focused
No Study

nutrition therapy recommended eating at least two meals

per day [29,39], without skipping Suhoor [29,39], and advised
to preferably delay the Suhoor meal [39]. One study applied
1
2
3
4
5
6
7
8

the structured nutrition therapy with the incorporation of

12 diabetes research and clinical practice 172 (2021) 108530

diabetes-specific formula during Ramadan [39]. Other In non-Ramadan fasting, the use of structured nutrition
Ramadan-focused elements of education included advice on therapy together with the diabetes-specific formula (DSF) as
recognizing and management of hypoglycemia, when to meal replacement had positive effect on weight management
break a fast, adjusting medications, appropriate physical and glycemic control in individuals with obesity and T2D [43],
activity, and self-monitoring blood glucose. Few studies pro- improving at the same time the adequacy and quality of the
vided support via telemonitoring [35] or a social networking diet. A recent study identified that the use of DSF as part of
support system [39] together with the guidance from the Mus- the structured nutrition therapy during Ramadan fasting
lim leaders [29,35]. reduced fasting glucose, triglycerides (TG), and self-
monitoring glucose profiles at pre-dawn and pre-bedtime vs.
3.5. Analyses of key features the standard care [39]. The intervention also improved dietary
intake by reducing carbohydrates and increasing protein and
Out of the studies comparing an intervention vs. control fiber intake, which may have contributed to lowering TG
(Table 3), four documented at least one positive outcomes in levels vs. the standard care group [39]. A previous meta-
glucose levels, anthropometric or lipid profiles [30,32,36,39]. analysis showed increased TG during Ramadan after receiv-
Features of nutrition plans that appeared to have favorable ing Ramadan-focused education, which was associated with
clinical outcomes included personalized dietary prescription excessive caloric intake and weight gain in T2D [25]. Hence,
[39], distributing carbohydrate equally between meals [39], the findings from Mohd Yusof et al. confirmed the benefits
providing meal plan [30,39], adjusting food intake to suit the and feasibility of prescribing the DSF as part of Ramadan-
Ramadan period [32,36], recommending preferred food focused nutrition therapy in T2D during Ramadan fasting [39].
choices [32] and incorporating diabetes-specific formula as While the reviewed studies determined the effect of nutri-
part of Suhoor or snack [39] (Table 3). tion therapy components during Ramadan fasting, data on
changes in dietary intake were limited. The diet of individuals
with T2D who undertook Ramadan fasting was not optimal in
4. Discussion composition, with low compliance rates. The nature of fast-
ing during daytime and feasting at night together with the
The narrative review provides evidence of the effectiveness of consumption of carbohydrate-rich foods during Ramadan
Ramadan-focused nutrition therapy in improving at least one constitute a challenge for people with T2D to achieve or
clinical outcome, including glycemic control, body weight, and maintain their target glycemic goals. Excessive carbohydrate
lipid profile in people with diabetes. The key features of nutri- consumption leads to an increase in postprandial hyper-
tion therapy that resulted in favourable clinical outcomes dur- glycemia. On the other hand, following Ramadan-focused
ing Ramadan fasting included: personalized meal plan to meet nutrition therapy improved patients’ intake of fibre and pro-
individual calorie needs while adjusting patients’ food prefer- tein, and reduced carbohydrates and sugar intakes [29,39].
ences to suit Ramadan fasting with equal distribution of car- Although Yeoh et al. observed an increase in dietary fats, this
bohydrates between Suhoor and Iftar or snacks as needed was still within the recommended intake range, which
[30,32,36,39]. All these components are consistent with the explained the benefits on body weight parameters especially
recommendations of the Ramadan nutrition plan published among females with T2D [31].
by IDF-DAR practical guidelines [4,40], based on the key princi- With Ramadan-focused nutrition education, there was a
ples of diabetes medical nutrition therapy (MNT) [41]. reduction or maintenance in rates or frequencies of hypo-
The DAR-SaFa Program and the IDF-DAR Practical Guideli- glycemia in all studies except for one [37] who conducted
nes outline recommendations of delivering Ramadan nutri- the intervention in diabetes patients with kidney function
tion plan [4,40], based on the key principles of diabetes MNT impairment. Patients with CKD are at higher risk of hypo-
[41]. The overall objective of MNT during Ramadan fasting is glycemia even in normal circumstances due to multiple
to ensure appropriate energy intake (i) with balanced propor- pathophysiological changes associated with reduced func-
tions of macronutrients to avoid hypoglycemia and weight tional renal mass [44]. Despite higher rates of hypoglycemia
gain (ii) distribute dietary carbohydrate evenly between in the CKD patients, their glycemic control and renal profiles
Suhoor and Iftar to control the rise in post-meal glucose and did not worsen throughout Ramadan, suggesting the benefits
(iii) control other comorbidities including hyperlipidemia. of Ramadan-focused education based on DAR-SaFa along
The provision of MNT by a dietitian demonstrated significant with close monitoring using CGMS.
improvement in HbA1c by 0.43% and other metabolic control To our knowledge, this is the first narrative review that dis-
parameters during non-Ramadan fasting [42]. We did not cussed the effectiveness of nutrition therapy during Ramadan
quantitatively determine the changes in HbA1c and other fasting for people with diabetes. We included recent studies
metabolic parameters in this narrative review. However, the from several countries, which comprise of heterogeneous
benefits observed were consistent with a meta-analysis of Muslim populations with various genetic makeup, lifestyle
Ramadan-focused education programs, leading to a signifi- behaviours, cultural habits, and food preferences.
cant reduction in HbA1c by 0.46% and an improvement in Our review has some limitations. We did not perform
LDL-cholesterol [25]. The longer study duration of 6– meta-analyses of the study findings; hence, we could not
12 months in non-Ramadan interventions vs. 1–4 months quantify the outcome measures such as hypoglycemia rates,
during Ramadan fasting, multiple encounters (2–4 visits) in and changes in HbA1c or body weight. Heterogeneity of
the Ramadan-focused nutrition therapy arms, along with methodology (such as study duration, definition of hypo-
pre-Ramadan education may explain the desired changes. glycemia, diabetes treatment modality, and components of
 diabetes research and clinical practice 172 (2021) 108530 13

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