On the occasion of the 72nd World Health Assembly, the World Heart Federation (WHF) and the International Diabetes Federation (IDF) organised a side event focused on how to decrease CVD-related premature mortality among people with diabetes and the role of Universal Health Coverage in achieving this.
The event took place in Geneva onMay 22, 2019 and speakers included:
Dr Larry Sperling, Katz Professor in Preventive Cardiology and Director of the Emory Heart Disease Prevention Center
Ms Stela Prgomelja, Vice-President of the Diabetes Association of Serbia and member of IDF Blue Circle Voices
Dr Brett Giroir, US Assistant Secretary of Health
Mr Veli Auveinen, Economist from the Finnish Ministry
Dr Cherian Varghese, NCD Management Coordinator, WHO
Mr Lucas Xavier de Oliveira, Nursing student at the University of Sao Paolo
Why we need to join forces to fight CVD in people with diabetes
Diabetes and cardiovascular disease (CVD) are global epidemics. They are among the leading causes of morbidity and mortality worldwide, particularly affecting people in low- and middle-income countries. CVD is a leading cause of death and disability in people with diabetes , who are up to three times more likely to have CVD.
Improving awareness and education of CVD is key to its prevention. In 2018, IDF conducted a global survey — Taking Diabetes to Heart — to assess CVD awareness among people living with Type 2 diabetes. The results showed that people with type 2 diabetes underestimated their CVD risk, despite a high incidence of CVD events, and that awareness of CVD among people with diabetes is insufficient. Two thirds of respondents indicated they needed more information on the signs and symptoms of CVD, and half needed more information on CVD risk factors – despite the majority (3 in 4) having discussed their CVD risk with a health professional.
Another key pillar of CVD prevention among people with diabetes is access to affordable and uninterrupted appropriate health services, care and medicines. 2019 will be a crucial year for global advocacy on access to NCDs care, with the United Nations (UN) High Level Meeting (HLM) on Universal Health Coverage (UHC) taking place in September. In the run-up to the UHC HLM, WHA provides an ideal opportunity to promote the importance of improved access to diabetes and CVD care and medicines as a cost-effective way of controlling the CVD epidemic among people with diabetes and improve health outcomes.
Improved education and access to care and medicines are only possible with a health-in-all-policies approach and increased funding. Ministries of Finance, through public-private partnership mechanism with key stakeholders, need to develop innovative ways of financing diabetes and CVD prevention and management, including the taxation of unhealthy products. Levies on low-nutrient energy-dense foods will result in increased revenues that can be used to strengthen health systems. These taxes could encourage healthier choices.
The WHF and IDF side event will bring together key experts on diabetes and CVD education and care, people living with diabetes and CVD, and policymakers. The in-depth discussion will focus on how to achieve Sustainable Development Goal (SDG) 3 “Ensure Healthy Lives and Promote Wellbeing for All at All Ages” and the targets 3.4 - 30% decrease of NCD-related premature mortality – and 3.8 – achieve Universal Health Coverage (UHC) – by 2030.
Fasting during the holy month of Ramadan is one of the five pillars of Islam and commemorates the time when the Holy Quran was revealed to Muhhammad. The month-long (29-30 day) fast is obligatory for all healthy Muslims who have reached puberty. Followers must refrain from eating and drinking between dawn and sunset, and must abstain from using oral medications, sexual activity and smoking.
The timing of Ramadan is based on the lunar calendar (355 days per lunar year), which is shorter than the Gregorian (Western) calendar, and Ramadan occurs 10–11 days earlier each every year. This means that the duration of daylight fasting varies according to the time of year in which Ramadan falls. In some parts of the world, daylight can be as long as 20 hours in the peak of summer.
Ramadan is widely observed across the world. Followers must refrain from eating and drinking between dawn and sunset, and must also abstain from using oral medications, sexual activity and smoking. It is believed that spiritual rewards for good deeds are multiplied during Ramadan, and there is an intense desire to participate in fasting, even among those who could seek exemption, such as the elderly, children, the disabled, and pregnant women.
Many Muslims, even those who could seek exemption, have an intense desire to participate in fasting during Ramadan.
Fasting is mandatory for all Muslim adults, with certain groups exempted, such as those with an illness – this may include some individuals with diabetes. Because of the metabolic nature of the disease, people with diabetes are at particular risk of complications from marked changes in food and fluid intake. Potential health hazards include low blood glucose (hypoglycaemia), high blood glucose (hyperglycaemia), dehydration and acute metabolic complications such as diabetic ketoacidosis (DKA).
Estimates suggest that there are 150 million Muslims with diabetes worldwide. Despite being exempt, many people with diabetes participate in fasting during Ramadan. Therefore, Ramadan has a major impact on the management of diabetes in the Muslim population.
Fasting and diabetes
It is important that the decision about whether to fast is made on an individual basis in consultation with a healthcare provider, taking into account the severity of illness and the level of risk involved. A cornerstone of managing diabetes during Ramadan is patient education, which should include information on risks, glucose monitoring, nutrition, exercise and medication.
Studies have shown that pre-Ramadan counselling reduces the episodes of low blood glucose. Pre-Ramadan education provides a platform to remind people with diabetes about the importance of diet and exercise, and that regular glucose monitoring is essential to avoid complications, while reassuring them that this does not invalidate the fast.
Fasting during Ramadan may provide enduring benefits. Indeed, Ramadan can provide an opportunity for a better lifestyle, facilitating weight loss and stopping smoking. For people with diabetes who choose to fast, Ramadan may help to strengthen the therapeutic alliance between patient and physician, and may provide an opportunity to improve diabetes management, with a focus on self-care and the regulation of medication and meal timing.
What to know and do?
Know your risk: As per the Holy Quran, there are groups of people who might make themselves ill by fasting. Based on medical and religious advice, it is recommended to visit your doctor 6-8 weeks before Ramadan to understand your risk category before deciding to fast. If your doctor advises not to fast, you will get the same Thawab (reward).
Check your blood glucose regularly: Blood glucose measurement and insulin injection do not break the fast and are important. They are your window to know your blood glucose levels and manage your diabetes. Changes in eating habits during Ramadan may affect your blood glucose and therefore it is important check blood glucose levels regularly.
People at very high risk (even if not fasting) should check blood glucose levels 3-4 times a day
People at moderate or low risk should check blood glucose levels 1-2 times a day
Medication adjustments during fasting: Talk to your doctor about the adjustments required to the dose, timing or type of medication to reduce the risk of low blood sugar.
When to break the fast? All people with diabetes should break the fast if:
Blood glucose is lower than 70 mg/dl (3.9 m mol/L). Re-check within one hour if blood glucose is in the range 70-90 mg/dl (50- 3.9 m mol/L)
Blood glucose is higher than 300 mg/dl (16.6 m mol/L)*
Symptoms of hypoglycemia, hyperglycemia, dehydration or acute illness occur
Exercising during Ramadan: perform regular light-to moderate exercise. Rigorous exercise is not recommended during fasting because of the increased risk of low blood glucose and/or dehydration. Physical exertions involved in Tarawih prayers, such as bowing, kneeling and rising, should be considered part of your daily exercise activities.
When the month of Ramadan ends, avoid over-eating (especially sweets) during Eid-ul-Fitr, as it may lead to high blood glucose. Visit your doctor to obtain guidance on changing the medication back to the previous schedule.
Dietary advice for people with diabetes during fasting
Divide daily calories between suhoor and iftar, plus 1-2 snacks if necessary
Ensure meals are well balanced: 45-50% carbohydrate 20-30% protein <35% fat
Include plenty of fruit, vegetables and salads
Minimise foods that are high in saturated fats (ghee, samosas, pakoras)
Use small amounts of oil when cooking (olive, rapeseed)
Stay hydrated between sunset and sunrise by drinking water or other non-sweetened beverages. Avoid caffeinated, sweetened drinks and sugary desserts
Include low glycaemic index, high fibre foods that release energy slowly before and after fasting (granary bread, beans, rice)
Healthy recipes for Ramadan
Click on the images below to download the preparation instructions. The original ingredients have been modified to align with healthy nutritional recommendations so we recommend using the ingredients as shown in the images.
Suhoor (pre-dawn meal)
IFTAR (evening meal)
IDF-DAR Practical Guidelines
With the global prevalence of diabetes continuing to increase, and the number of fasting Muslims set to rise, the importance of effective guidelines for the management of diabetes during Ramadan fasting is clear. The IDF-DAR Practical Guidelines provide healthcare professionals with both background and practical information, as well as management recommendations to optimise the care delivered to people with diabetes who plan to fast during Ramadan.
What is Universal Health Coverage and why is it important for people with diabetes?
The World Health Organisation defines Universal Health Coverage (UHC) as a situation where all individuals and communities receive the health services they need without suffering financial hardship. UHC is a central piece of the Sustainable Development Goals and, in 2015, all UN Member States committed to achieving it by 2030.
Diabetes is a condition that requires lifelong management. Without UHC, people with diabetes can face catastrophic health expenditures and impoverishment as a result of the medical expenses incurred to manage their condition effectively to avoid or delay complications.
What is the High Level Meeting on UHC?
Despite global commitments, half of the world’s population does not yet have full coverage of essential health services at an affordable price. The United Nations (UN) is hosting a High Level Meeting (HLM) on UHC on September 23, 2019, to mobilise the highest political support for UHC and adopt a political declaration with milestones for the achievement of UHC by 2030.
What is IDF doing on occasion of the UN HLM on UHC?
On occasion of the UN HLM on UHC, IDF is urging global leaders to leave no one behind and ensure all people with diabetes have access to essential care and medicines at an affordable price.
You can download and read IDF's call to action by clicking on the picture. The document is available in English, French, Spanish and Italian.
Support IDF's campaign on social media in the run-up to the HLM on UHC:
IDF has launched a UHC selfie campaign focused on the cost of essential diabetes care around the world. You can find examples of these selfies in our Flickr gallery. IDF is currently developing a calculator for the selfie campaign. To find out how you can participate, please visit this page again in the coming weeks. By participating, you can support IDF in ensuring that the voices of people with diabetes are heard.
In addition to the selfie campaign, IDF has created some advocacy videos featuring members from its BCV and YLD networks. Click on the videos to watch.
Don't forget to share with your friends and networks!
425 million people were living with diabetes in 2017. Most of these cases are type 2 diabetes. Another 352 million people were estimated to be at high risk of developing type 2 diabetes in 2017.
While there are a number of factors that influence the development of type 2 diabetes, it is evident that the most influential are lifestyle behaviours commonly associated with urbanization. These include consumption of unhealthy foods and inactive lifestyles with sedentary behaviour. Randomised controlled trials from different parts of the world, including Finland, USA, China and India, have established the that lifestyle modification with physical activity and/or healthy diet can delay or prevent the onset of type 2 diabetes.
Modern lifestyles are characterised by physical inactivity and long sedentary periods. Community-based interventions can reach individuals and families through campaigns, education, social marketing and encourage physical activity both inside and outside school and the workplace. IDF recommends physical activity at least between three to five days a week, for a minimum of 30-45 minutes.
Taking a life course perspective is essential for preventing type 2 diabetes and its complications. Early in life, when eating and physical activity habits are established and when the long-term regulation of energy balance may be programmed, there is an especially critical window to prevent the development of overweight and reduce the risk of type 2 diabetes. Healthy lifestyles can improve health outcomes at later stages of life as well.
Population based interventions and policies allow healthy choices through policies in trade, agriculture, transport and urban planning to become more accessible and easy. Healthy choices can be promoted in specific settings (school, workplace and home) and contribute to better health for everyone. They include exercising regularly and eating wisely which will help to maintain normal levels of blood glucose, blood pressure and lipids.