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Risk of diabetic ketoacidosis during Ramadan fasting: A critical reappraisal.
Beshyah, SA, Chowdhury, TA, Ghouri, N, Lakhdar, AA
Diabetes research and clinical practice. 2019;:290-298
Abstract
OBJECTIVES To evaluate the validity of the perceived increased risk and the actual occurrence of DKA observed during fasting in Ramadan. METHODS This is a non-systematic narrative review of the literature on the occurrence of DKA during Ramadan. Online databases (PubMed, Google Scholar, Cochrane Database, Medline OVID and CINAHL EBSCO) were searched. Three research questions are addressed 1. What is the basis of the expert opinion on the risk for DKA? 2. What is the likelihood that DKA is precipitated by Ramadan fast? and 3. What is the frequency of observed DKA during Ramadan? RESULTS The expert opinion suggesting a risk of DKA during Ramadan fasting was proposed with no evidence in the early writing on Ramadan fasting and has been reiterated and propagated since then. However, from first principles, DKA is not readily precipitated by the usual stress-free metabolic environment induced by Ramadan fasting with the exception of cases involved in the usual risk factors for metabolic decompensation. Furthermore, recent studies could not document any increase in observed DKA during Ramadan fasting in retrospective, prospective and database studies. CONCLUSIONS The current state of knowledge and evidence suggests the risk of DKA is not increased during Ramadan fasting.
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An Evolutionary Perspective on Why Food Overconsumption Impairs Cognition.
Mattson, MP
Trends in cognitive sciences. 2019;(3):200-212
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Abstract
Brain structures and neuronal networks that mediate spatial navigation, decision-making, sociality, and creativity evolved, in part, to enable success in food acquisition. Here, I discuss evidence suggesting that the reason that overconsumption of energy-rich foods negatively impacts cognition is that signaling pathways that evolved to respond adaptively to food scarcity are relatively disengaged in the setting of continuous food availability. Obesity impairs cognition and increases the risk for some psychiatric disorders and dementias. Moreover, maternal and paternal obesity predispose offspring to poor cognitive outcomes by epigenetic molecular mechanisms. Neural signaling pathways that evolved to bolster cognition in settings of food insecurity can be stimulated by intermittent fasting and exercise to support the cognitive health of current and future generations.
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Considerations for clinicians treating Muslim patients with psychiatric disorders during Ramadan.
Furqan, Z, Awaad, R, Kurdyak, P, Husain, MI, Husain, N, Zaheer, J
The lancet. Psychiatry. 2019;(7):556-557
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Sodium-glucose co-transporter inhibitors: Medications that mimic fasting for cardiovascular prevention.
Giaccari, A
Diabetes, obesity & metabolism. 2019;(10):2211-2218
Abstract
Recent evidence that some diabetes drugs can prevent cardiovascular disease (CVD) has profoundly modified the treatment approach to type 2 diabetes mellitus. Sodium-glucose co-transporter-2 (SGLT2) inhibitors and almost all glucagon-like peptide-1 receptor agonists (GLP-1RAs) have been shown, beyond their effect on glucose control, to lead to a significant decrease in the cardiovascular burden of diabetes. Although these results are well known, the mechanisms of action by which they prevent cardiovascular events are still poorly understood. Both GLP-1RAs and SGLT2 inhibitors promote weight loss, although through different mechanisms. SGLT2 inhibitors promote glycosuria, leading to significant caloric deficit and weight loss. Similarly, GLP-1RAs, probably through an anorexic effect on certain brain areas, inhibit calorie intake, with ensuing weight loss. Although it features less prominently in current treatment pathways, pioglitazone has also demonstrated cardiovascular benefits. Pioglitazone profoundly modifies several mechanisms and risk factors responsible for CVD; however, these mechanisms certainly do not include weight loss. Obesity, and consequent insulin resistance, are well known risk factors for CVD, and it would appear logical to attribute the positive cardiovascular effects of these two classes of drugs to weight loss. The direct metabolic effects of these two classes, however, are profoundly different. The present review proposes a unifying hypothesis to explain the reduction in CVD through three different mechanisms of curbing free fatty acid excess, all leading to the common mechanism of cellular caloric restriction. If this hypothesis is correct, the excellent results obtained with SGLT2 inhibitors could be attributed to their close simulation of fasting.
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Nonfasting versus fasting lipid profile for cardiovascular risk prediction.
Langsted, A, Nordestgaard, BG
Pathology. 2019;(2):131-141
Abstract
Before 2009 essentially all societies, guidelines, and statements required fasting before measuring a lipid profile for cardiovascular risk prediction. This was mainly due to the increase seen in triglycerides during a fat tolerance test. However, individuals eat much less fat during a normal day and nonfasting triglycerides have been shown to be superior to fasting in predicting cardiovascular risk. Lipids and lipoproteins only change minimally in response to normal food intake: in four large prospective studies, maximal mean changes were +0.3 mmol/L (26 mg/dL) for triglycerides, -0.2 mmol/L (8 mg/dL) for total cholesterol, -0.2 mmol/L (8 mg/dL) for LDL cholesterol, and -0.1 mmol/L (4 mg/dL) for HDL cholesterol. Further, in 108,602 individuals from the Copenhagen General Population Study in random nonfasting samples, the highest versus the lowest quartile of triglycerides, total cholesterol, LDL cholesterol, remnant cholesterol, non-HDL cholesterol, lipoprotein(a), and apolipoprotein B were all associated with higher risk of both ischaemic heart disease and myocardial infarction. Finally, lipid-lowering trials using nonfasting blood samples for assessment of lipid levels found that reducing levels of nonfasting lipids reduced the risk of cardiovascular disease. To date there is no sound scientific evidence as to why fasting should be superior to nonfasting when evaluating a lipid profile for cardiovascular risk prediction. Indeed, nonfasting samples rather than fasting samples have many obvious advantages. First, it would simplify blood sampling in the laboratory. Second, it would benefit the patient, avoiding the inconvenience of fasting and therefore needing to have blood drawn early in the day. Third, for individuals with diabetes, the risk of hypoglycaemia due to fasting would be minimised. Many countries are currently changing their guidelines towards a consensus on measuring a lipid profile for cardiovascular risk prediction in the nonfasting state, simplifying blood sampling for patients, laboratories, and clinicians worldwide.
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Beta cell function in type 1 diabetes determined from clinical and fasting biochemical variables.
Wentworth, JM, Bediaga, NG, Giles, LC, Ehlers, M, Gitelman, SE, Geyer, S, Evans-Molina, C, Harrison, LC, , , ,
Diabetologia. 2019;(1):33-40
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Abstract
AIMS/HYPOTHESIS Beta cell function in type 1 diabetes is commonly assessed as the average plasma C-peptide concentration over 2 h following a mixed-meal test (CPAVE). Monitoring of disease progression and response to disease-modifying therapy would benefit from a simpler, more convenient and less costly measure. Therefore, we determined whether CPAVE could be reliably estimated from routine clinical variables. METHODS Clinical and fasting biochemical data from eight randomised therapy trials involving participants with recently diagnosed type 1 diabetes were used to develop and validate linear models to estimate CPAVE and to test their accuracy in estimating loss of beta cell function and response to immune therapy. RESULTS A model based on disease duration, BMI, insulin dose, HbA1c, fasting plasma C-peptide and fasting plasma glucose most accurately estimated loss of beta cell function (area under the receiver operating characteristic curve [AUROC] 0.89 [95% CI 0.87, 0.92]) and was superior to the commonly used insulin-dose-adjusted HbA1c (IDAA1c) measure (AUROC 0.72 [95% CI 0.68, 0.76]). Model-estimated CPAVE (CPEST) reliably identified treatment effects in randomised trials. CPEST, compared with CPAVE, required only a modest (up to 17%) increase in sample size for equivalent statistical power. CONCLUSIONS/INTERPRETATION CPEST, approximated from six variables at a single time point, accurately identifies loss of beta cell function in type 1 diabetes and is comparable to CPAVE for identifying treatment effects. CPEST could serve as a convenient and economical measure of beta cell function in the clinic and as a primary outcome measure in trials of disease-modifying therapy in type 1 diabetes.
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The value of Continuous Glucose Monitoring and Self-Monitoring of Blood Glucose in patients with Gestational Diabetes Mellitus during Ramadan fasting.
Afandi, B, Hassanein, M, Roubi, S, Nagelkerke, N
Diabetes research and clinical practice. 2019;:260-264
Abstract
INTRODUCTION In order to achieve the recommended glycemic control, women with Gestational Diabetes Mellitus (GDM) are instructed to self-monitor blood glucose (SMBG) regularly. The purpose of this study was to evaluate glucose readings provided by Continuous Glucose Monitoring (CGM) and SMBG in GDM patients during Ramadan fasting. METHODS This is a prospective observational study that recruited GDM patients treated with diet ± metformin were enrolled. They agreed to wear the iPro®2 ProfessionalCGM device and to do SMBG by glucose reading meters, during fasting and after meals. We evaluated the rates of hypoglycemia and hyperglycemia in each approach. The frequency and timing of SMBG was investigated. RESULTS Twenty-five patients were recruited. A total of 36,628 readings by CGM device and 408 readings using glucose meters and were captured. Average glucose level was 103 ± 8 mg/dl (5.7 ± 0.4 mmol/l) and 113 ± 14 mg/d (6.28 ± 0.8 mmol/L) on CGM and glucose meters respectively. The rate of hyperglycemia was 5.65% and 14.2% and hypoglycemia was 4.35% and 1.5% using CGM and glucose meters respectively. While all hypoglycemic episodes occurred between 16:00-19:00 in both approaches, only 38 readings (9%) of SMBG readings were done in that time frame. CONCLUSION Although the frequency of SMBG using glucose meters for women with GDM and fasting Ramadan was acceptable, the timing was not. CGM detected more hypoglycemia and less hyperglycemia than SMBG. Relying on Intermittent SMBG in the management of GDM patients during Ramadan fasting might be misleading.
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Is exercise best served on an empty stomach?
Wallis, GA, Gonzalez, JT
The Proceedings of the Nutrition Society. 2019;(1):110-117
Abstract
The objective of this review paper is to evaluate the impact of undertaking aerobic exercise in the overnight-fasted v. fed-state, in the context of optimising the health benefits of regular physical activity. Conducting a single bout of aerobic exercise in the overnight-fasted v. fed-state can differentially modulate the aspects of metabolism and energy balance behaviours. This includes, but is not limited to, increased utilisation of fat as a fuel source, improved plasma lipid profiles, enhanced activation of molecular signalling pathways related to fuel metabolism in skeletal muscle and adipose tissue, and reductions in energy intake over the course of a day. The impact of a single bout of overnight-fasted v. fed-state exercise on short-term glycaemic control is variable, being affected by the experimental conditions, the time frame of measurement and possibly the subject population studied. The health response to undertaking overnight-fasted v. fed-state exercise for a sustained period of time in the form of exercise training is less clear, due to a limited number of studies. From the extant literature, there is evidence that overnight-fasted exercise in young, healthy men can enhance training-induced adaptations in skeletal muscle metabolic profile, and mitigate against the negative consequences of short-term excess energy intake on glucose tolerance compared with exercising in the fed-state. Nonetheless, further long-term studies are required, particularly in populations at-risk or living with cardio-metabolic disease to elucidate if feeding status prior to exercise modulates metabolism or energy balance behaviours to an extent that could impact upon the health or therapeutic benefits of exercise.
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The glycaemic sixer [glycaemic hexad].
Kalra, S
JPMA. The Journal of the Pakistan Medical Association. 2018;(10):1541-1542
Abstract
This opinion piece describes a cricket-based analogy, the Glycaemic Sixer, for diabetes care. The hexad lists six glycaemic parameters which must be targeted to achieve optimal cardiovascular outcomes. All six parameters, i.e., fasting glucose, post prandial glucose, glycosylated haemoglobin, avoidance of hypoglycaemia, avoidance of nocturnal hypoglycaemia, and minimization of glycaemic variability, are associated with cardiovascular outcomes. Hence, equal attention must be paid to all these while planning strategies and choosing drugs for diabetes management. The Glycaemic Sixer promotes safety along with efficacy, and supports institution of individualized, patient centred care, using evidence-based therapeutic agents.
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Fasting or Non-fasting Lipids for Atherosclerotic Cardiovascular Disease Risk Assessment and Treatment?
Rahman, F, Blumenthal, RS, Jones, SR, Martin, SS, Gluckman, TJ, Whelton, SP
Current atherosclerosis reports. 2018;(3):14
Abstract
PURPOSE OF REVIEW Dyslipidemia is a major modifiable risk factor for atherosclerotic cardiovascular disease (ASCVD); however, lipid testing for risk assessment and treatment surveillance has been underutilized. Several factors likely account for this, including the common practice of measuring lipid levels in the fasting state, which often necessitates that patients return for an additional visit. In this review, we evaluate potential advantages and cautions associated with measuring lipids in the non-fasting state. RECENT FINDINGS There is similar performance with the use of either fasting or non-fasting total cholesterol and HDL cholesterol in ASCVD risk assessment. Observational studies demonstrate that in comparison to fasting levels, non-fasting triglycerides are approximately 20% higher on average, although the magnitude of difference is subject to substantial inter-patient variability. Higher triglycerides can lead to the under-estimation of low-density lipoprotein cholesterol (LDL-C) by approximately 10 mg/dL or more when calculated using the Friedewald equation. This is especially clinically relevant at low LDL-C levels, although a novel validated algorithm for LDL-C estimation largely overcomes this limitation. Non-fasting lipid assessment is reasonable in many clinical circumstances given that ASCVD risk prediction is similar using fasting or non-fasting lipid values and because LDL-C can be accurately estimated using modern methods. Allowing the option for non-fasting lipid assessment can reduce a barrier to lipid testing and can facilitate a more convenient assessment of ASCVD risk with the ultimate potential effect of reducing the global burden of ASCVD. However, certain patients such as those with severe hypertriglyceridemias or high-risk patients being treated to low LDL-C levels may still need fasting lipid panels performed for precise diagnosis and to standardize therapeutic monitoring.