The DDG practice recommendations are updated regularly during the second half of
the calendar year. Please ensure that you read and cite the respective current
version.
Updates To Content And Different Recommendations Compared To The Previous
Year’s Version
Recommendation 1:
Update of data on the population group with a migration background (see point 1.3
Demographics for Germany).
Reason:
There is more recent data on demographics for Germany.
Supporting references:
[9]
[11]
Recommendation 2:
Data from 2019 show that the use of
systems for continuous glucose monitoring (CGM) is 30 %
more common in patients without a migration background
than in those with a migration background [41] (see point 1.7.2 Particularities in the
therapy).
Reason:
New insights into the use of digital supporting
tools in diabetes therapy and blood glucose control.
Supporting references:
[38]
Recommendation 3:
Update of the effectiveness of common
diabetes medications such as alpha-glucosidase inhibitors
(acarbose) and insulin.
Reason:
New findings on the effectiveness of common
diabetes drugs in people of non-European origin.
Supporting references:
[42]
Recommendation 4:
New data on the increasing use of
online translation services in healthcare (see point 1.8.2
Language)
Reason:
The importance of online translation services is also
growing in healthcare and diabetes treatment for people
with migration experience.
Recommendation 5:
Prevention of diabetes mellitus and its
secondary diseases were included (see point 1.11 Prevention)
Reason:
To date, the therapeutic approaches and specificities of
diabetes mellitus in people of non-German origin have mainly
been discussed. The revised edition now also takes into account
the prevention of diabetes mellitus and its complications.
Recommendation 6:
Expansion and updating of the topic of
fasting in people with type 1 diabetes (see point 1.13 Ramadan
– One Month of Fasting)
Reason:
New insights into the possibility of fasting in people
with type 1 diabetes mellitus and with the help of certain drug
regimens.
Supporting references:
[93]
[97]
The practical recommendation “Diabetes and Migration” of the German
Diabetes Association (DDG) was prepared for the first time and in cooperation with
the Austrian Diabetes Association (ÖDG). The practice recommendation is
intended to supplement the existing guidelines on diabetes mellitus and provides
practical recommendations for the diagnosis, therapy and care of people with
diabetes mellitus who come from different linguistic and cultural backgrounds.
Definition (migration background and generation)
Definition (migration background and generation)
The population with a migration background includes people with their own migration
experience and all those who have at least one parent or grandparent to whom this
applies [1]. Different definitions or changes in
what is understood by a migrant background make it difficult to have a uniform and
consistent view [2].
In the context of therapy, in addition to the pure migration background, the
generational affiliation or the place of socialization plays an important role:
-
First generation: socialization took place in the country of origin and
immigration took place in adulthood.
-
Second generation: children of the first generation born here or whose family
moved here when they were under 18 years old. Their socialization has taken
place, at least in part, in Germany.
-
Third generation: first-generation grandchildren and second-generation
children. Their socialization has taken place entirely in Germany.
Epidemiological overview
In many official statistics and routine data, nationality is still considered the
predominant distinguishing feature, which is used to represent only a selective part
of the migrant population, however socio-demographic information is missing. People
with a migration background often differ in their health situation from people
without a migration background simply because of their younger average age or their
poorer social situation. To make meaningful comparisons, the influence of these
factors must be taken into account [2].
Despite an incomplete data situation in Germany, studies from similar countries make
it possible to obtain an approximate picture of the situation in Germany. It is
estimated that more than 600 000 people with type 2 diabetes and with a migration
background live in Germany today. This number will continue to grow in the coming
years for two main reasons. Firstly, the first generation of migrants is
increasingly reaching retirement age and secondly, many of the refugees coming to
Germany come from countries with a high risk of developing type 2 diabetes. This
risk is increased when they migrate to industrialized countries [3].
Demographics for Germany
Currently, the microcensus is the only available official source of data on the
population group with a migration background. In 2020, the microcensus was
methodologically revised. Therefore, the results from the reporting year 2020 and
onwards can only be compared with previous years to a limited extent [4].
In 2021, about 22.3 million (27.2%) people in Germany had a migration
background. This represented an increase of 2.0% compared to the previous
year. The most important countries of origin continue to be Turkey (12%),
followed by Poland (10%), Russia (7%), Kazakhstan (6%) and
Syria (5%) [5].
Almost two-thirds (62%) of all persons with a migrant background are
immigrants from other European countries or their descendants. This corresponds to
13.9 million people, 7.5 million of whom have roots in other Member States of the
European Union. The second most important region of origin is Asia. 5.1 million
immigrants from Asia and their descendants account for 23% of people with a
migrant background; of these, 3.5 million have a connection to the Near and Middle
East. Almost 1.1 million people (5%) have roots in Africa. Another 0.7
million people (3%) are immigrants from North, Central and South America and
Australia and their descendants [5].
Of the 22.3 million people with a migrant background, 7.2 million (32%) speak
exclusively German at home and an additional 3.1 million (14%) predominantly
German. This corresponds to almost half (46%) of all people with a migration
background. The most frequently used languages in addition to German are Turkish
(8%), Russian (7%) and Arabic (5%). Almost half
(49%) of all people with a migrant background are multilingual and speak
both German and (at least) one other language at home. This applies to only
2% of people without a migrant background [6].
The associated particularities of the population structure confer greater cultural
diversity for the German society. At the same time, this population structure poses
challenges on the health care system.
Prevalence for Germany
The risk of developing type 2 diabetes varies greatly among migrant populations.
People from South and Central America, North and Sub-Saharan Africa, the Middle East
and South Asia have very high prevalences [7].
Numerous European and American studies confirm that the prevalence and incidence of
type 2 diabetes and its associated mortality are usually higher among migrants than
among the native population [8]. In addition,
migrants experience type 2 diabetes on average 5–10 years earlier and are
more likely to develop the disease than the populations in their home countries and
in the host countries [3]
[9].
A recent meta-analysis of the prevalence of ethnic minorities in Europe shows that
migrants from South and Central America show a 30% higher risk than the
native population. In contrast, the risk is almost three times higher for migrants
from the Middle East and North Africa and almost four times higher for migrants from
South Asia [10]
[11]
[12].
Women of Turkish origin in Sweden have a 3-times higher risk of diabetes compared
to
Swedish women, whereas there is hardly any difference between Turkish men and
Swedish men. This is the same for the hospitalization risk due to type 2 diabetes,
although this effect is reduced in the second generation [13]. A study conducted in 7 European countries for
30 immigrant groups shows that the diabetes mortality rate for men and women is 90
and 120% higher, respectively, compared to the native population [14]. In addition, people with type 2 diabetes from
Asia, the Middle East and Sub-Saharan Africa have a particularly high risk of
microvascular complications: diabetic retinopathy, nephropathy, and peripheral
neuropathy [15].
Increased disease rates are also seen for gestational diabetes. In Germany, for
example, women of Turkish origin have a 33% higher incidence rate of
gestational diabetes compared to autochthonous population [16].
Demographics for Austria
According to Statistics Austria, 8.9 million people live in Austria, of which a total
of 2.24 million have a migrant background. This is 51 900 more than in 2017,
which represents a share of about 25.4% [17]. The group of first-generation immigrants comprises about
1 528 000 persons, while second-generation immigrants amount to
around 542 000. The largest group comes from Germany with 217 000 persons,
followed by 138 000 Romanians. In the course of 2019, these have overtaken Serbian
(122 100) and Turkish citizens (117 600). Bosnia and Herzegovina occupy fifth place
(96 600). The citizens of Hungary, Croatia, Poland, Syria and Afghanistan are in
sixth to tenth place. In addition, migrants from Slovakia, Russia, Italy, Bulgaria,
Kosovo, and Macedonia are also strongly represented in Austria [17]. Since February 2022, an increasing number of
people have been fleeing from the Ukraine to Germany and Austria. Therefore, the
treatment of this population group will become relevant.
Prevalence for Austria
In Austria, the group of people suffering from diabetes mellitus is currently
estimated at 515 000 to 809 000 people (7 to 11%). The total includes 368
000 to 515 000 medically-diagnosed diabetes cases (approx. 5 to 7%) and an
estimated 147 000 to 294 000 diabetics (approx. 2 to 4%). In the group of 0
to 14-year-olds, the estimated proportion of people with diabetes is about
0.1% in Austria (approx. 1600 children) [18]. According to the IDF (International Diabetes Federation), the
prevalence of diabetes in Austria is 9.3%. Among migrants, the prevalence is
about 10–12%, although a high number of unrecorded and undiagnosed
patients is assumed [19]. In Vienna, a patient
survey confirmed a diabetes prevalence of 10% among Turkish migrants. Every
third respondent had an increased risk of developing diabetes within the next five
years [20]. Compared to native Austrians, migrants
are 1.39 times more likely to develop diabetes among men and 3.4 times more likely
among women [21].
Specifics in the diagnosis and therapy of migrants with diabetes
Specifics in the diagnosis and therapy of migrants with diabetes
Due to their different cultural and individual backgrounds (level of education,
reason and duration of migration, etc.), migrants often have a different
understanding of health, healthcare, illness – especially chronic illness
– than the native population. Knowledge of the connections between lifestyle
and disease, and of factors influencing the course of the disease can also differ
from that of the native population [22]. In
addition, lifestyle and particularly nutritional habits change as a result of the
new social and economic conditions. Furthermore, external risk factors –
structural deprivation – play an important role: these include
location-specific (e. g. high unemployment), psychosocial (e. g.
insecure employment conditions) and environmental (e. g. noise, air
pollution, climate change, etc.) factors [23].
The cultural background and in some cases a lack of language skills, illiteracy, low
socio-economic status and difficulties in the process of cultural adaptation
(acculturation) can therefore hinder access to medical preventative care and
treatment. This is also reflected in the low percentage of migrants who seek
preventative medical checkups [24].
Specifics in diagnostics
Various changes can influence or falsify the HbA1c value in immigrants
and their offspring [25]
[26].
The average HbA1c value is higher for Americans of African descent
than for Americans of European descent. The same applies to population groups
from Sub-Saharan Africa compared to European populations [27]
[28]
[29]. Among adults in South Africa, the
sensitivity and specificity of HbA1c for the detection of prediabetes
are extremely poor [30]. Therefore,
HbA1c ≧ 6.0% has been proposed as a new
diagnostic cut-off for this population group [31].
The Inuit have significantly higher HbA1c values than Danish
individuals for any given fasting and 2 h glucose value and for each
category of glucose tolerance [32]. Further
research is needed to find the optimal ethnically-specific interface for
screening [33].
Causes of the observed ethnic differences include frequent hematological changes
in these population groups. Iron deficiency (ID) is associated with up to
2% increased HbA1c in the absence of hyperglycemia. It is
recommended to consider iron levels when interpreting HbA1c in
African populations [27]
[34].
Hemoglobinopathies are the most common inherited single-gene disorders. According
to the WHO, 5.2% of the world’s population carries a variant
[35].
HbS (sickle cell trait) occurs frequently in Africa, the Mediterranean, the Near
East and India. This results in a shortening of the erythrocyte lifetime. The
HbA1c value may be falsely higher due to this shortened lifetime
[35]. However, due to structural changes
in the globin molecule, decreased HbA1c values can also be measured
[28].
HbE is a hemoglobin variant with a mutation in the beta-globin gene, the most
common Hb variant in Southeast Asia. Statistically and clinically
significantly-higher results are observed due to the presence of the HbE trait
[32].
HbB (changes in the beta-globin gene): β thalassemias occur more
frequently in the Mediterranean, Southeast Asia, India, China and the Middle
East. In southern Africa, one in three has some form of α thalassemia;
in South-East Asia it is more than 60% of the population [36]. The G202A variant in the X-linked gene of
glucose-6-phosphate dehydrogenase (G6PD) also has a T allele frequency of
11% in African Americans and up to 25% in populations from
Sub-Saharan Africa; it is associated with an absolute decrease in
HbA1c of 0.81% units (95% CI 0.66–0.96)
per allele in hemizygous men and 0.68% units (95% CI
0.38–0.97) in homozygous women compared to homozygous carriers of the A
allele [34].
Specifics in the therapy
There is evidence that therapy differs depending on cultural affiliation. For
example, a study in the UK showed that an escalation of therapy in the course of
treatment for diabetes mellitus occurs much less frequently in people of dark
skin and South Asians than in the white population [37]. The reasons for this have not yet been sufficiently
investigated, but the causes are likely multi-factorial. An important factor
seems to be the lack of permanent medical care. Generally, the frequency of
prescription of SGLT2 inhibitors has increased. However, this is not seen for
patients with heart failure, kidney disease and cardiovascular disease. The drug
was prescribed less in the population from sub-Saharan Africa, women, and
households with lower income [38].
Further results suggest that standardized care may reduce existing ethnic
inequalities in type 2 diabetes-associated chronic kidney disease (CKD) [39]. For example, an accelerated decline in the
glomerular filtration rate was found in people of non-European origin who
already had proteinuria and high blood pressure [40]. However, a randomized controlled trial showed that participants
of African descent developed CKD less frequently than European participants,
although both groups had similarly high levels of microalbuminuria,
macroalbuminuria and kidney failure [39]. The
authors attribute this to active monitoring of kidney function and emphasize
that younger adults may benefit most from the interventions [40].
Data from 2019 show that the use of systems for continuous blood glucose
monitoring (CGM) is 30% more common in patients without a migration
background than in those with a migration background [41]. The proposed reason is the lack of
language settings of the CGM systems used for the languages of the largest
immigration groups in Germany. Extending the language offer to Turkish, Russian
and Arabic would be very useful. Furthermore, CGM systems and flash glucose
systems are not fully covered by the health insurance schemes in Germany, and
patients therefore have to co-pay approx. 10 € per month. This
constitutes an additional hurdle for the use of these systems among migrant
groups. In Austria, the financial contribution to GCM systems and flash glucose
systems varies according to the health insurance company.
Particularities in substance selection
For pharmacological background information on the drugs listed below, we refer
the readers to the specialist literature or summary of product characteristics.
Here, we only discuss the migration-related specifics that are known scientific
literature. At this point, only the differences in migration medicine known from
studies are discussed.
Metformin: Efficacy may be reduced in Asians as a result of gene polymorphisms
[42]
[43].
DPP-4 inhibitors: a systematic review found that DPP-4 inhibitors are more
effective in Japanese than in non-Japanese and are generally more effective in
Asians than in non-Asians [42]
[44].
GLP-1 agonist: In a meta-analysis (15 studies), it was shown that GLP-1 agonist
lower the HbA1c value in Asians more than in non-Asians [45]. The pharmacokinetic data of dulaglutide
does not differ depending on ethnicity, weight, sex and age [46]. Semaglutide treatment results in a uniform
reduction in HbA1c without differences in origin or ethnicity
(sustain post-hoc analyses) [47].
SGLT2-inhibitors: In the subgroup of people from Asia with type 2 diabetes
mellitus, the EMPA-REG study showed the same positive effects (mainly a
reduction in the incidence and progression of nephropathy) as in the remainder
of the study population. There were also no significant differences to people of
African descent [48].
Alpha-glucosidase inhibitors (acarbose):
In a meta-analysis, there were no differences in HbA1c reduction
between Asians and non-Asians [42].
Insulin:
A meta-analysis showed a lower HbA1c reduction in Asians receiving
insulin therapy (glargine) than in non-Asians, with no differences in
hypoglycemia and fasting blood glucose [42].
Treatment of people with migration background and diabetes in practice
Treatment of people with migration background and diabetes in practice
General approaches
The goals in the treatment of people with a migration background and diabetes are
to enable an optimal transfer of knowledge and to strengthen the
patients’ personal responsibility. Appropriate information events are
useful in order to increase knowledge about diabetes mellitus, the secondary and
concomitant diseases as well as the relationship between the disease, diet and
lifestyle. Starting points for this can be found in the respective communities
with the involvement of all interest groups (such as cultural associations,
religious communities, health insurance companies, medical societies,
media).
In the inpatient and outpatient sector – particularly in practices
specializing in diabetology – a culturally-sensitive approach with
appropriately trained personnel (with special knowledge and understanding of the
cultural influence on treatment) is an important prerequisite for successful
therapy.
If a language barrier exists and if it is possible, training and treatment in the
native language should be provided which match the educational level and
lifestyle of the patient.
Intercultural content should be incorporated into the education, training and
continuing education of healthcare professionals (doctors, diabetes advisors,
diabetes assistants, dieticians, nutritionists, nursing staff, etc.). It is also
recommended that bicultural and multilingual personnel will be increasingly
trained and promoted in health services. In medical history taking and therapy,
it is important to consider bio-psychosocial influences and thus to keep
religious attitudes as well as interfamilial and social hierarchies in mind
([Fig. 1]).
Fig. 1 Bio-psychosocial determinants to be considered during
patient consultations. (f, female; m, male; d, diverse) Source:
© Faize Berger.
Language
Communication during treatment should be in one language (treatment language). If
necessary or possible, interpreting should be done by specialized interpreters
or language and culture mediators.
Generally, children should not serve as translators. In consideration of the
situation, if a professional interpreter is not available, adult relatives can
be involved to assist. It is advisable to communicate using clear, simple, short
sentences and general terms. If necessary, another language (including
colloquial language) can be used or medical personnel with appropriate language
skills can be involved, taking into account the obligation of
confidentiality.
The DocCards shown below are recommended as a practical orientation aid for the
procedure in doctor-patient consultations with and without an interpreter (refer
to DocCards under DDG working materials
http://migration.deutsche-diabetesgesellschaft.de/arbeitsmaterialien/doccards.html)
([Fig. 2] and [3])
Fig. 2 DocCard – Language barriers.
Fig. 3 DocCard – Interpreting.
In their guidelines on patients’ rights, the Federal Ministry of Health
(Bundesministerium für Gesundheit) and the Federal Ministry of Justice
(Bundesministerium für Justiz) point out that every patient has the
right to adequate opportunities for communication and appropriate information
and consultation, as well as to thorough and qualified treatment. However, they
do not mention the financing of professional interpreting services ([Fig. 4]). The legal framework shown in [Fig. 4] is not valid for Austria.
Fig. 4 General conditions for the education of patients and
service providers based on the BMG and BMJ guidelines on patient rights
in Germany 2005 [Source for the guidelines: Federal Ministry of Health
and Federal Ministry of Justice (Bundesministerium für
Gesundheit und Bundesministerium für Justiz) (2007): Patient
rights in Germany, Guidelines for Doctors (Patientenrechte in
Deutschland, Leitfaden für Ärztinnen/Ärzte).
Berlin.
https://www.bundesgesundheitsministerium.de/uploads/publications/BMG-G-G407-Patientenrechte-Deutschland.pdf
(Dated: 2015–09–20)]] and the Law for the Improvement of
Patients’ Rights (Gesetz zur Verbesserung der Rechte von
Patientinnen und Patienten) [Bundesgesetzblatt Jahrgang 2013 Teil I Nr.
9, p. 277–282]. BMG: Federal Ministry of Health
(Bundesministerium für Gesundheit), BMJ: Federal Ministry of
Justice (Bundesministerium für Justiz).
The importance of online translation services is also growing in healthcare.
Currently, more than 100 languages can be translated via websites or apps. The
use of these tools in healthcare is underresearched and there are many
differences in the quality of translation. Studies show a strong variability in
the accuracy of the translation of medical content. While the accuracy is
highest for Romance languages with 80%, for Slavic languages about
60% accuracy. For African and Asian languages, however, it only reaches
40–50% [49].
For the future, a rapid further development of apps and websites for the medical
sector is to be expected. Commonly used online translation services include:
-
Google Translator (app or website)
-
Bing (app and website)
-
MediBabble (medical translation app)
-
Canopy Speak Medical Translation (medical translation app)
-
CALD Assist (app specifically for health workers)
-
Naver Papago Translate (app)
-
SayHi Translate (app)
Simultaneous translation equipment also already exists.
Telephone interpreting services enable better doctor-patient communication when
patients and doctors speak different languages. Nevertheless, the interpreter
may need to see the patient physically in order to better advise the doctor. To
this end, interpretation services using videoconferencing should be further
developed [50].
Nutrition
Different cultures and regions sometimes have very individual eating habits.
Food culture is shaped by geographical, historical, sociological, economic and
psychological characteristics of a society and is shared by the corresponding
members of a particular community. Culture is a fundamental determinant of
“what we eat” [51].
Migrants often have different dietary habits than natives. They sometimes prefer
other foods, often eat more carbohydrates, have different meal concepts, a
different understanding of portions, and different food preparation forms and
food combinations. Their nutritional concepts are usually based on their own
traditional cuisine, personal habits, and they also adopt the eating habits of
the local population, often resulting in a new “mixed cuisine”
[52], [53]. It is not uncommon for special foods to be procured from the
home countries. Migrants from some cultures have little use for the weight
information in local recipes when cooking.
People have a highly variable postprandial glucose response to identical foods.
Individualized culturally-sensitive counseling improves compliance [54] and is well-accepted as a weight loss
intervention measure [55].
In this context, fasting during Ramadan – religiously-influenced food
selection and fasting regulations (see below), pregnancy and shift work play a
particular role.
In everyday practice, knowledge of the main carbohydrate sources and in what form
and when the carbohydrates are eaten is indispensable. The following practice
tool for the nutritional habits ([Tab. 1]) of
migrants is intended to provide initial information and assistance. A pragmatic
regional breakdown with information on common cuisine forms the basis. The main
sources of carbohydrates and other regional characteristics are presented in
addition to the type (warm/cold) and number of meals.
Tab. 1 Practice tool for nutrition. This table does not
replace the official food-based dietary guidelines.
|
Geograhic origin
|
Meals c=cold w=warm
|
Time of main meal
|
Main carbohydrate sources
|
Beverages
|
Particularities
|
|
Mediterranean cuisine
|
|
E.g. Turkey, Mediterranean coast, Greece, Spain, France,
Italy, Israel1, 2
|
c-w-w
|
Evening (relatively late)
|
Wheat bread (flatbread/sourdough bread), pasta, rice,
bulgur, polenta (Italy), potatoes
|
Tea (drunken with or without sugar),
coffee+milk+sugar, mocha+sugar, wine
(from midday), alcoholic with meze/tapas
|
Ayran=yoghurt drink, mainly yoghurt sauces (TR), lots
of vegetables, lots of fruit (fresh and dried), nuts, pastry
specialties (pizza, croissant, börek, pita etc.),
fish*, Helva (sweetened sesame paste), religiously
kosher and halal preparations Fats: mostly olive oil
|
|
Balkan cuisine (Southeast Europe)
|
|
E.g. Bulgaria, Serbia, Kosovo, Montenegro, Albania,
Bosnia-Herzegovina, Slovenia, Croatia, Romania, Hungary
|
c-w-w
|
Evening
|
Wheat bread, potatoes, rice, pastry specialties (filled dough
pockets, burek)
|
Tea (drunken with or without sugar), coffee
|
Similar to the Mediterranean cuisine, with a high fat
content, lots of meat* and sauces, sweet yeast bread
(Povitica, Kolachki), polenta, dumplings (Romania, Hungary),
pudding for dessert
|
|
Eastern European Cuisine
|
|
E.g. Russia, Poland, Baltic States6
|
c-w-w
|
Lunch and dinner
|
Rye bread, buckwheat (Kasha, blinies), dumplings, rice,
filled dough pockets, potatoes, wheat bread
|
Tea (drunken with sugar, honey, milk or jam) wine, vodka,
brandy
|
Fatty, semolina/oatmeal porridge prepared for
breakfast with milk, a lot of stew with meat broth, a lot of
sauces, soups with potatoes as the main ingredient, desserts
prepared with condensed milk
|
|
Oriental cuisine
|
|
E.g. Iran, Afghanistan, Syria, Arab Mediterranean countries,
Southeast Anatolia1, 5
|
c-w-w
|
Evening (relatively late)
|
Rice, wheat bread, legumes (especially chickpeas)
|
Tea (black, green and apple tea) and coffee (usually
sweetened with lots of sugar or honey)
|
Fruit: Pomegranate (fruit and as syrup), dates, figs, pastry
specialties: hearty (like burek) and sweet (like baklava),
dessert: Knefeh (wheat dough with cheese, rose water and
sugar syrup), baklava, Halawa (sweetened sesame paste), many
herbs, no pork, rice dishes sometimes with vermicelli, tahin
(sesame paste), hummus (chickpea paste), nuts. Fats and
oils: olive oil, butter, sheep’s tail fat
(delicacy)
|
|
North African Cuisine
|
|
E.g. Morocco/Maghreb, Mauritania³
|
w-w-w
|
Evening
|
Wheat bread, rice, potatoes (in tagine), pulses
(chickpeas/humus), couscous, shombi (milk, rice or
corn in the evening), baghrir (semolina with honey or sugar
for breakfast), makroudh (semolina with date filling)
|
Juices, mint tea+sugar
|
Harira soup (with rice or vermicelli served with dates),
Shombi (milk, rice or corn/evening), Tagin with
caramelized fruits (Tagine Lahlou), fruit,
meat *, fish * Fats and
oils: olive oil, argan oil and butter
|
|
African cuisine (Excluding North Africa)
|
|
Sub-Saharan African countries
|
w-w-w
|
Evening
|
Yams (starch supplier), plantains, sweet potatoes, potatoes,
cassava, millet
|
Millet beer, Mageu (fermented corn porridge), beer, raw sugar
schnapps, coffee liqueur, but also wine
|
Fufu (a tough porridge made from various ingredients such as
plantains, sweet potatoes, corn, manioc and/or
yams), curry with meat, fruits, fish* , lots of
meat*, Koeksister (fried pastry dessert which is
submerged in a special syrup and dried), Maroelas (the sour
tasting fruits of the Marula tree)
|
|
East Asian Cuisine
|
|
E.g. Philippines, Indonesia, Japan, China4,7
|
w-w-w
|
Lunch and dinner
|
Rice (incl. sushi), rice noodles (Thai), egg noodles
(Indonesia), wheat, wheat noodles (Udon) also made of
buckwheat, mung beans or sweet potatoes
|
Tea, rice wine
|
Sweet and sour sauces, many soybean products, few dairy
products in China, Japan and South Korea, short grain rice
at every meal, a lot of (also raw) fish*, briefly
cooked fresh vegetables, soups
|
|
South Asian Cuisine
|
|
E.g. India, Sri Lanka, Pakistan5
|
w-w-w
|
Lunch
|
Rice, wheat bread (naan, chapati), filled dough pockets
(roti)
|
(Mango) lassi (thick and sweet yoghurt drink), tea with milk
and honey/sugar (chai)
|
Spicy food, strong spices, coconut milk, lots of fried and
breaded foods, yoghurt sauces, legumes (including dhal),
tea+milk+sugar, pickled fruits (rayta,
pachadi), milk-based desserts
|
|
South American cuisine
|
|
E.g. Brazil, Venezuela, Argentina, Peru,
Caribbean5
|
c-w-w
|
Evening
|
Amaranth, quinoa, corn, rice, wheat, baked or fried
empanadas, tapioca starch (obtained from
cassava/massava flour), black beans, potatoes
|
Cachaca (sugar cane brandy), coconut juice, tequila, rum,
wine, mate tea
|
Lots of fruit (e. g. camu camu, guavas, mango,
papaya, passion fruit), soups, cuscuz (steamed food made
from corn flour, the sweet variety of coconut couscous, in
Brazil), often very spicy.Tacos (made from corn flour are
very popular in Mexico), pulses (especially beans),
regionally heavy on meat*.
|
*Fish and meat are only considered if they represent an
exceptional part of the diet in the region. Sources:
1 J. Boucher, Mediterranean Eating Pattern, Spectrum Diabetes
Journals 2017, S.: 1,
https://doi.org/10.2337/ds16–0074;
2 K. Gedrich, U. Ottersdorf, Ernährung und Raum:
Regionale und ethnische Ernährungsweisen in Deutschland, S.:104.
Bundesforschungsanstalt für Ernährung, Karlsruhe, 2002;
3 F. Heidenhof.
https://www.bzfe.de/inhalt/hochkultur-bringt-esskultur-essen-in-nordafrika-und-im-nahen-osten-4808.html;
4 F. Deng, A. Zhang, C. Chan,
doi:10.3389/fendo.2013.00 108; 5 N. Mora, S. H.
Golden, Understanding Cultural influences on Dietary Habits in Asian,
Middle Eastern, and Latino Patients with Type 2 Diabetes: A Review of
current Literature and Future Directions. Curr Diab Rep (2017) 17:
126/https://doi.org/10.1007/s11%20
892–017–0952–6; 6 Kittler, Sucher,
Nelms. Food and Culture 7e, 2017, S 184; 7 Kittler, Sucher, Nelms. Food
and Culture, 7e, 2017, S. 305, S. 326.
Cuisines are quite diverse around the world and there is also a great deal of
regional diversity. Nevertheless, it should be noted that many drinks have now
made their way into many food cultures around the world, such as soft drinks,
energy drinks, drinks sweetened with sweeteners, and some beer types.
Training and counseling material
Training and counseling material
Both culturally-sensitive individual training courses and target group-adapted group
counseling enable effective communication of information about diabetes mellitus,
its secondary and concomitant diseases, perception of hypo- and hyperglycemia and
therapy.
Therapies tailored to the cultural needs of study participants in randomized
controlled trials show a reduction in HbA1c and body fat values [56].
Training materials with culturally-sensitive examples should be available at least
in
the respective native languages and ideally be bilingual.
The use of pictograms, illustrations, symbols, demonstration utensils, especially
pen
needles, test strips, applicators, blood glucose devices, etc. is recommended not
only to reach the illiterate people with diabetes, but also to provide effective
training. It is important for the portion sizes to be accurate when creating images
of food and the like. For illiterates, the use of blood glucose devices with a large
display or speaking meters is recommended (also available in foreign languages). At
present, there is hardly any training material available on diabetes technology in
the context of migration. The instructions for use of the devices cannot replace the
need for training materials.
A selection of foreign language information and training materials has been compiled
on the homepage of the DDG’s Working Group on Diabetes and Migrants. In
addition, the DDG’s Working Group on Diabetes and Migrants has actively
brought together important institutions in order to provide professional,
culturally-sensitive working materials for nutritional counseling in diabetes
mellitus.
Communication strategies and training should be tailored to a vulnerable group
and/or gender and adapted to all known barriers. Family and friends play an
important role in this. For example, it is conceivable to involve family members in
cooking or exercise courses [57]. In Sweden, a
culturally-adapted diabetes education model has been developed that includes
participants’ individual beliefs about health and disease, their knowledge
of diabetes and their experiences with self-care [58]. Indeed, lifestyle interventions among migrant groups and ethnic
minorities appear to be only moderately effective in lowering the HbA1c value [57]. A recent systematic review with meta-analysis
also finds that lifestyle interventions with peer support have positive effects on
clinical outcomes such as the HbA1c value, as well as on the knowledge and practices
of diabetes self-management [59].
Pregnancy – Gestational Diabetes Mellitus (GDM)
Pregnancy – Gestational Diabetes Mellitus (GDM)
GDM occurs with above-average frequency among women with a migration background [60], but due to the great heterogeneity, migrant
women, or women with a migration background in general do not represent a specific
uniform risk group for GDM. The extent of the influence depends on the prevalence
of
the individual risk factors, the respective ethnicity, and the specific migration
situation [61].
A retrospective analysis conducted in Austria clearly shows the diversity of the
individual migrant populations in relation to GDM. Between 2013 and 2015, data
collected from 3293 pregnant women at a university hospital were evaluated taking
into account the country of birth. The GDM risk for Turkish immigrant women was
approximately twice as high as the risk of pregnant women born in Austria. The risk
was about 1.5 times higher among women from Romania, Hungary, and Macedonia than
among the native population [60].
Risk factors favoring the development of GDM were more frequently observed among
migrant women from Turkey, the Near and Middle East and Africa than among women born
in Austria or migrant women from other European countries. These include the
genetically-higher risk of developing type 2 diabetes over the course of life,
overweight/obesity, higher parity and higher GDM risk. The situation is
similar with the probability of developing manifest type 2 diabetes mellitus later
in life.
GDM is associated with an increased risk of premature birth and caesarean section,
while migrants have a higher risk of all complications considered, regardless of
GDM. However, the increase in all these risks, including macrosomia or large for
gestational age (LGA), remains marginal when women with GDM receive more attention
from the healthcare system and equivalent treatment [62].
Women with low socio-economic status and migrant backgrounds often find it difficult
to understand the requirements of GDM self-management. In order to improve adherence
to treatment plans, they need educational and support services that are culturally
appropriate and aimed at lower levels of literacy [63].
Obesity/excess weight
In certain migrant populations – especially among women from the Middle
East, Turkey, and North and South Africa – numerous studies have found a
markedly high prevalence of excess weight and obesity. For pregnant women from
Turkey and North Africa, a French birth cohort study of 18 000 women also showed
a significantly higher risk of excess weight/obesity and GDM. Women from
Eastern Europe and Asia, on the other hand, have a lower weight risk but still a
higher risk of developing GDM than pregnant women without a migration background
[64].
Pre-conception care of migrant women already reduces the risk of
complications.
Nutrition
Nutrition, coupled with cultural and traditional particularities, is of increased
importance during pregnancy. For example, it is commonly observed that pregnant
women think that they should “eat for two”. The idea of giving
in to pregnancy cravings is also often consciously supported.
It is therefore absolutely essential to provide culturally-sensitive training,
develop an individual nutrition plan and closely monitor its implementation and
adaptation, especially with migrant women who come from risk regions and as part
of planned or existing pregnancy. The practice tool on nutrition ([Tab. 1]) can be used for orientation and as a
preliminary aid regarding the main carbohydrate sources in the respective native
cuisine.
Vitamin D deficiency
Direct sunlight is very high in the country of origin for people from Africa, the
Near and Middle East and the Indo-Asian region and their vitamin D status is
usually insufficient after migration to Europe. The results of studies on the
effect of vitamin D deficiency on GDM are not clear [65]. In general, however, a vitamin D deficiency is an avoidable
health risk.
Therefore, especially in pregnant migrant women from the above-mentioned regions,
the vitamin D status should be assessed and risk minimization should be
considered, if necessary by substitution.
Breastfeeding
Breastfeeding the newborn for at least 3 months reduces the mother’s risk
of diabetes mellitus [66]. The World Health
Organization (WHO) therefore recommends full breastfeeding for at least 6
months. “Initial analyses of the breastfeeding behavior surveyed in
KiGGS show that children with a migration background are breastfed more
frequently and also longer than those without a migration background.
88.1% of Russian-German children and 79.3% of children of
Turkish origin were breastfed more frequently compared to children without a
migration background (76.2%). The fact that only three-quarters of the
children grouped under “other” migrants received breast milk is
an impressive indication of the heterogeneity within the migrant
population” [67].
Migrant women should be motivated to breastfeed for at least 6 months, especially
if they are overweight/obese.
Treatment with antibiotics
Antibiotic therapy during pregnancy leads to disrupted development of the
microbiome in the newborn’s intestine [68] in the postnatal period. Especially among the women who have fled
to Germany since 2015, it can be assumed that they may have been exposed to
antibiotic therapy more frequently than native women with and without a
migration background. On the one hand, the group described above is more likely
to carry multi-resistant germs, which could be an indicator for antibiotic use,
and on the other hand, there are also culturally-determined convictions
regarding antibiotic therapy. For example, therapy with antibiotics is almost a
cultural norm in the Iraqi population, and patients consider the prescription of
antibiotics as an adequate standard therapy.
Therapy adherence and antenatal care for migrant women
As with some other subgroups, migrant women are particularly at risk for GDM due
to the often low level of education, communication deficits, low health skills,
and high unemployment. Without professional help, they find it difficult to find
their way around within the healthcare system. They often know neither the care
processes and the importance of preparing for pregnancy, nor the prenatal and
postnatal examinations that are a regular part of medical care and preventative
care in Germany. Doctors should inform their patients with a migration
background about preventative care options at an early stage. Physicians in
general practice, on the one hand, report that younger migrant women who are
familiar with the care structures regularly attend pre- and postnatal check-ups
and show at least similar, if not significantly higher, compliance compared to
native women of their age. On the other hand, there are women who come to a
delivery center or hospital with labor pains and the medical team can hardly
obtain information about the course of their pregnancy to date due to
communication problems. The team may also encounter these pregnant women for the
first time and find that they have received little or no medical advice or
support during their pregnancy. In connection with diabetes, pregnancy and
migration, other factors such as health literacy, understanding of
illness/health, influence and role of family, traditions, customs and
rituals must also be taken into account. In the group of women who migrate
because they are forced to flee and who have no proof of identity, other aspects
such as traumatization, violence (including rape) and a higher number of
abortions can be added in this context [69].
It would be desirable for the treating physicians to have a basic understanding
of how pregnancy and maternity are understood in the respective cultures as well
as basic psychosocial knowledge for dealing with trauma victims.
Prevention
Diabetes mellitus is one of the ten most common causes of death according to the
latest WHO ranking. The number of deaths due to diabetes mellitus has increased by
70% in 20 years – a very serious situation [19].
Especially people with a migration background are less likely to make use of
preventive examinations and preventive measures. In the case of cholesterol and
blood glucose determinations, significantly more than half of the persons aged 15
years and above (regardless of migration status) (60.7 and 61.4%
respectively) had these examinations carried out in the year prior to the survey.
A
small proportion of this age group (8.8 and 8.1% respectively) has never
made use of them. As with blood pressure, measurements for cholesterol and blood
glucose were performed more frequently in women and more frequently with increasing
age [70].
One of the most important aspects is the lack or non-existent level of knowledge to
adopt preventive and therapeutic measures.
In a project in Vienna, Turkish migrants in general medical practices were
interviewed in their mother tongue, on the one hand about the prevalence of obesity
and diabetes or diabetes risk, and on the other hand about health literacy,
especially knowledge of risk factors. Compared to a (smaller) group of Austrians,
these 115 men and 327 women were older and had a higher BMI. About 11%
already had diabetes mellitus; two-thirds had an increased to very high risk of
developing diabetes mellitus within the next 5 years. Women and the elderly were
more affected. Knowledge of risk factors was poorer among migrants than among native
Austrians.
This study also found that more than a third of respondents were overweight and more
than half were obese. Female respondents in particular were more often obese than
male respondents and, in comparison, more often obese than migrant women of other
origins [70].
The obesity epidemic has also become a serious public health problem with an upward
trend. The prevalence of obesity worldwide has more than doubled in the last 30
years and has reached epidemic proportions [71].
Obesity plays a causal role in three of the four most common non-communicable
diseases [72]. More than half of adult Austrians
are overweight or obese. Children and adolescents are also affected by the obesity
epidemic.
Prevention in childhood
According to WHO estimates, 22 million children under the age of 5 years
overweight worldwide [73].
The first 1000 days of a child’s life, from conception to about 2 years
of age, are a critical period for early prevention of obesity. During this time,
nutrition is crucial. Often referred to as “metabolic or developmental
programming,” a nutrient imbalance in infant and maternal diets can have
long-term effects on health later in life [74].
Sixty percent of children who were overweight before puberty carry an increased
risk of remaining overweight or obese in adulthood [75].
Children and adolescents with overweight or obesity also suffer from
psychological comorbidities at an above-average rate, which can also result in
poorer academic performance and reduced self-esteem [76].
In the case of children with a migrant background, the data is even more
concerning. In 2012, Segna and colleagues showed among 25000 children
(2–16 years) in Vienna how the child’s mother tongue related to
weight status. Of these children, 46% had a migrant background. In
particular, children with Turkish as a native language, but also children with
other linguistic backgrounds, were significantly more often overweight and obese
than children with German as a native language [77].
Something similar was also shown at 12 Bielefeld schools. There, data from
children aged 6–7 years were evaluated on the basis of measurements of
weight and height, as well as calculation of BMI according to the IOTF criteria.
This study also described that children with a migration background were more
frequently overweight and obese than children of German origin [78].
Another study showed that children with a migrant background are less physically
active and more likely to be overweight [79].
The Child and Adolescent Health Survey (KiGGS) evaluated indicators and
determinants of the health status of 0- to 17-year-old children in Germany. The
authors derived concrete recommendations for priority health policy action were
also derived and published from these findings. Thus, the KiGGS data contribute
to “evidence-based prevention” [80].
Valuable data can be found in the WHO – European Childhood Obesity
Surveillance Initiative, which was conducted in 23 countries in children between
6–9 years of age [81].
The planning and implementation of health promotion and prevention measures
should be based on valid and up-to-date population-based data. As the scientific
evidence shows, this should already start at preschool age.
Systemic prevention and individual prevention
Prevention approaches differ in terms of the temporal perspective in the course
of disease, comparing primary (before the onset of the disease, e. g.
weight loss to prevent diabetes), secondary prevention (in the early stages of a
disease, for example to avoid diabetes complications) and tertiary prevention
(in the case of a disease manifestation, e. g. to prevent
newly-occurring complications).
As the German Health Report Diabetes 2022 shows, both systemic prevention
measures and individual behavioral prevention are important for the prevention
of type 2 diabetes. Systemic prevention aims at the living environment of the
population in order to positively influence behavior through health-promoting
changes.
Such public health measures can be complex: this is why various measures can be
considered solely to promote healthy eating habits, such as advertising
restrictions, food labelling, product reformulations, the prominent placement of
healthy foods in certain settings such as canteens, subsidies and taxes, or bans
on the distribution of certain foods in specific settings such as schools [82].
Individual behavioral prevention, on the other hand, aims to influence the
behavior of individual risk groups. Studies have shown that people who are at an
increased risk for type 2 diabetes benefit from early detection and possible
lifestyle change interventions [83].
Risk screening and risk scores
The DDG propagates two diabetes risk calculators to estimate the risk of
developing type 2 diabetes [84]. First, the
DIfE – GERMAN DIABETES RISK TEST (DEUTSCHER
DIABETESRISIKO-TEST® – DRT) [85], which is provided as a culturally-adapted
version by the Robert Koch Institute, and second, the FIND-RISK [86].
Risk scores can support the exact determination of the absolute risk of disease
of individuals – a “precision prognostic”. Reducing the
risk of diabetes is a declared goal of the Prevention Act [87]. These prevention measures are independent
of migration status and apply to everyone.
Lifestyle changes: the sooner, the better
The effects of a permanent lifestyle change are now well documented by various
complex intervention studies. With increased physical exercise and reduced
calorie intake aiming at moderate weight loss, the incidence rate and the course
of an existing type 2 diabetes can be favorably influenced. Participants in the
American Diabetes Prevention Program (DPP) study were motivated to reduce weight
by 7% and to engage in physical activity of at least
150 min/week. After a median observation period of 2.8 years,
they recorded the most significant weight loss (approximately -5.6 kg)
and a 58% reduction in diabetes risk compared to metformin treatment and
the control group.
The lasting effect of lifestyle changes has been shown by recent data from a
follow-up study of the same participants, which was conducted 10 years after the
start of the study. Even though the participants of the “lifestyle
change” measure had gained some body weight again, the beneficial
influence on the risk of new disease was maintained (about 34% risk
reduction). According to the data, it is particularly worthwhile to exercise
more, eat healthy and control weight at a young age [88].
There is evidence that the first 5 years after migration may provide an
opportunity to take targeted action to maintain healthy eating habits [89].
Proven principles of lifestyle change
At the same time, some studies also provide information about promising lifestyle
changes.
-
Reduced calorie intake has a beneficial effect on body weight, blood
pressure, insulin sensitivity and fasting blood glucose after 24 months,
regardless of the composition of the food [90].
-
A reduction or modification of fat consumption is accompanied by an
initially-small reduction in cardiovascular risk, which becomes
increasingly clear with increasing study duration [91].
-
With the help of simple “nutritional patterns”, it is
possible to keep the weight stable. They include a high consumption of
fiber, fresh fruit, vegetables, as well as restricting meat and meat
products, butter, and high-fat cheeses [92].
-
For the goal of weight loss, increased physical activity should be
combined with reducing calories. Experts recommend both consuming fewer
calories and increasing physical activity to prevent muscle loss.
Exercise helps to stabilize achieved weight loss success. An additional
5 hours of exercise per week is recommended, which corresponds
to an additional consumption of about 2500 calories per week. Exercising
moderately on a regular basis is most effective: the decisive factor is
the duration, not the intensity.
General
Fasting is considered the voluntary complete or partial abstention from food,
beverages and luxury food over a certain period of time; this is in contrast to
starving where there is a lack of food. There are different reasons for fasting:
health, mental, religious or physical, among others.
Fasting type and duration can vary greatly depending on the reason for fasting.
In the following, the fasting month of Ramadan is discussed in more detail.
Ramadan – one month of fasting
Ramadan – one month of fasting
Approximately 1.6 billion people around the world live with Islamic religious
beliefs. Ramadan is the month of fasting for Muslims and the ninth month of the
Islamic lunar calendar [93]. Fasting during
Ramadan lasts one month. During the fasting period, from sunrise (Sahur=meal
at sunrise or beginning of fasting) to sunset (Iftar=meal after sunset or
breaking of fasting), no liquid or food may be consumed. Due to the lunar calendar,
the fasting period is shifted forward by about 10 to 11 days every year. People with
chronic diseases (including pregnant women and nursing mothers) are not obliged to
fast. Many devout Muslims with chronic diseases insist nevertheless on fasting but
this should only take place under medical supervision [94]. According to the EPIDIAR study, about 43% of patients with
type 1 diabetes and about 79% with type 2 diabetes fasted for at least 15
days during Ramadan [95]. A retrospective,
13-country study reported that 64% of patients fasted daily during Ramadan
and 94% fasted for at least 15 days during that period [96]. Fasting presents a special challenge for
people with diabetes and their therapists. In general, an adjustment or modification
of the existing therapy according to the current guideline recommendations of the
DDG or ÖDG should be referred to before the start of the fasting period. If
a person with diabetes wants to fast, the intake and dosages as well as the side
effects (especially minimizing the risk of hypoglycemia) of the medication have to
be adapted to the new eating habits. Since the main meal is at sunset, the day-night
rhythm is reversed. In accordance with this rhythm, some medications, especially
sulfonylureas and insulin therapy, need to be changed or their dosage adapted - the
prevention of hypoglycemia is the main priority. Further complications during
fasting are hyperglycemia, dehydration, increased risk of thrombosis and
ketoacidosis [97].
Since insulin injection is used to treat diabetes mellitus and not to replace or
support nutrition, i. e. eating and drinking, patients can perform their
insulin injections during fasting as prescribed by their doctors.
In 2021, the International Diabetes Federation (IDF) and Diabetes and Ramadan
Alliance (DAR) published a practice recommendation for patients with diabetes who
want to fast during Ramadan [94]. Patients are
assigned to different risk groups according to the assessment of their risk of
developing one or more complications (as mentioned above) during fasting ([Fig. 5]) [93].
Fig. 5 Risk assessment regarding the occurrence of one and/or more
complications during fasting. Source: Şat S, Aydinkoc-Tuzcu K,
Berger F et al. Diabetes and Migration (Update 2019). Wien Klin Wochenschr
2019; 131 (Suppl 1): 229–235.
In the DAR Global survey, only 60.2% of participants had access to diabetes
training, with only 50.7% (141/278) of participants under the age of
18 years receiving training, compared to 63.6% (490/771) of
participants aged≥18 years.
The risks associated with fasting are not the same for all people –
adolescents and adults – with type 1 diabetes.
Fasting during Ramadan is generally associated with a high risk of hypoglycemia and
hyperglycemia for people with type 1 diabetes. With well-structured pre-Ramadan
education programs, the risks associated with fasting can be reduced, and eligible
individuals can be allowed to fast under strict supervision and after adjusting the
insulin doses accordingly. Treatment adjustments should be made individually. The
following factors should be taken into account: pre-Ramadan attitude towards
diabetes, previous experience with Ramadan, availability of aids, level of education
and motivation for self-treatment. Different demographic characteristics affecting
the duration of fasting, access to insulin and glucose monitoring must be taken into
account in any risk assessment for safety fasting. Insulin analogs are preferable
to
conventional insulin regimens during fasting. Frequent Standrad Blood Glucose
Monitoring (SMBG) was previously essential and is now supported and partially
replaced by Constant Glucose Monitoring/Fasting Glucose Monitoring
(CGM/FGM) or sensor-based pump therapy. Modern insulin technology seems to
be very promising for enabling safe fasting [93].
Studies also recommend that healthcare professionals work together for shared
decision-making to address cultural differences and patients’ particular
cultural needs. A systematic review shows that patients and health professionals
should be informed about fasting during Ramadan and that knowledge should be spread
in the world’s major regional languages in order to disseminate the
information to educationally-disadvantaged communities [97].
Therapy dosage suggestions during the fasting period of Ramadan
Therapy dosage suggestions during the fasting period of Ramadan
The specified order of the substance groups does not correspond to the prioritization
of the use according to the current guideline.
Oral antidiabetic therapy [93] (Table
2)
There is evidence that therapy differs depending on cultural affiliation. For
example, a study in the UK showed that therapy escalation over the course of
treatment for diabetes mellitus occurs much less frequently in people from
Africa and South Asia than in the European population [37]. The reasons for this have not yet been
sufficiently investigated, but a multifactorial justification can be assumed. An
important factor seems to be the lack of permanent medical care.
Metformin
The dosage can remain unchanged, and will be taken at Sahur and Iftar. If it
is taken twice a day (e. g. 1000 mg of metformin), the
dosage should not be changed. In case of a triple dose (e. g.
500 mg of metformin) it is recommended to take 500 mg of
metformin at Sahur and 1000 mg at Iftar.
Acarbose
It is recommended to be taken with meals without changing the dosage.
Sulfonylureas (SH)
The basic recommendation is to change to another substance class with a lower
risk of hypoglycemia in accordance with the currently-valid guidelines of
the DDG or ÖDG.
If the SH therapy is nevertheless to be continued, a change to the newer
generations of sulfonylureas (e. g. gliclazide, glimepiride) is
recommended. In case of one single dose, a dose reduction of 25% is
recommended, as well as timing the dose to breaking the fast (Iftar). If two
doses are taken, it is recommended to reduce the morning dose as well (or
skip it if no meal is taken at Sahur) and take the second dose when breaking
the fast without changing the dose ([Tab.
2]).
Tab. 2 Therapy dosage suggestions during the fasting
period of Ramadan for oral antidiabetic therapy.
|
Medication [38]
|
Adjustments
|
Particularities
|
|
|
Dose adjustment
|
Time of administration
|
|
|
Metformin
|
Yes
|
At Iftar1 and Sahur2
|
Skip lunchtime dose, For 2×1000 mg:
maintain dose at Iftar and Sahur, For
3×500 mg: at Iftar 1000 mg and
Sahur 500 mg
|
|
Acarbose
|
None
|
At Iftar and Sahur
|
|
|
Sulfonylurea
|
Yes
|
Morning dose at Iftar, evening dose at Sahur
|
Preferably switch SH therapy to another substance group
with a low risk of hypoglycemia. If SH therapy is
further prescribed, then preferably glimepiride or
gliclazide; avoid glibenclamide. For a single
administration: take at Iftar, 25% dose
reduction with good control, if necessary. If
administered twice: reduce morning dose at Sahur by
25% if necessary
|
|
Glitazones
|
None
|
At Iftar or Sahur
|
|
|
DPP-4 inhibitors
|
None
|
At Iftar
|
|
|
GLP1 agonists
|
None
|
At Iftar or Sahur
|
|
|
SGLT2-inhibitors
|
None
|
At Iftar
|
Ensure that enough liquid is drunk after breaking the
fast (Iftar) until Sahur! Caution with insulin
deficiency: danger of euglycemic diabetic ketoacidosis
[38].
|
1 Iftar: Breaking the fast at sunset.; 2 Sahur:
Start of fasting at sunrise.
Glitazones
The dose is recommended without reduction at Iftar or Sahur.
Dipeptidyl peptidase-4 inhibitor (DPP-4 inhibitor)
Recent data show that DPP-4 inhibitors (especially vildagliptin, sitagliptin)
are a safe therapeutic alternative during fasting. The HbA1c value did not
differ significantly from SH [98]. The use
of DPP-4 inhibitors resulted in a lower risk of mild, symptomatic, and
severe hypoglycemia compared to SH [98]
[99]. The dose of a DPP-4
inhibitor is not changed and can be taken at Iftar [93].
Glucagon-like peptide-1 receptor agonist (GLP1-RA)
In the Treat-for-Ramadan study, Liraglutide showed a lower risk of
hypoglycemia than SH, as well as improvements in HbA1c and weight loss [94]. In addition, the LIRA-Ramadan study
demonstrated the efficacy and safety of liraglutide over a 52-week
observation period including fasting [94].
Liraglutide resulted in an improvement in fasting glucose levels, sustained
weight loss and a reduction in HbA1c [99].
Sodium-dependent glucose transporter-2 inhibitor (SGLT-2
inhibitor)
No dose reduction is recommended for this, the dose can be taken at Iftar. It
is important to drink enough liquids after breaking the fast (Iftar) up to
Sahur. Taking SGLT2-inhibitors is possible for well-adjusted diabetes
patients with stable metabolism, good kidney function and who do not have an
increased risk of dehydration [100].
In principle, the risk of hypoglycemia is low and the weight reduction caused
by renal glucosuria is beneficial. However, given the risk of euglycemic
diabetic ketoacidosis, caution is advised in cases of insulin deficiency
[101]. Ketone measurements are
required for all patients who decide to fast and are on SGLT2-inhibitor
therapy [102].
Combination preparations of different substance classes
The hypoglycemic effects and corresponding dose recommendation or adaptations
of the respective substance groups must be taken into account, as already
mentioned above ([Tab. 3]).
Tab. 3 Therapy dosage suggestions during the fasting
period of Ramadan for the insulin therapy.
|
Therapy (Insulin) [35]
|
Adjustments
|
Dosage
|
Particularities
|
|
|
One dose
|
Two doses
|
Three doses
|
|
|
BOT – basal insulin- supported oral therapy
|
Dose adjustment
|
Dose reduction 15–30%
|
Reduce the dose at Iftar1
15–30% and reduce the dose at
Sahur2 by 50%.
|
–
|
|
|
Administration
|
At Iftar
|
Move the morning dose to Iftar and move the evening dose
to Sahur
|
–
|
|
Rapid-acting insulin – functional insulin
therapy
|
Dose adjustment
|
None
|
Iftar dose unchanged, reduce Sahur dose by
25–50%
|
Reduce Sahur dose by 25–50%
|
Analog insulin recommended
|
|
Administration
|
At Iftar
|
Iftar and Sahur
|
Skip midday dose
|
|
|
Mixed insulins
|
Dose adjustment
|
None
|
Reduce Sahur dose by 25–50%
|
Reduce Sahur dose by 25–50%
|
|
|
Administration
|
Move to Iftar
|
Move morning dose to Iftar, move evening dose to
Sahur
|
Skip midday dose, otherwise the same as two doses
|
|
Insulin pump
|
Dose adjustment
|
Reduce the basal rate by 20–40%
3–4 h before Iftar, shortly after Iftar:
increase by 0–30%
|
Insulin bolus depends on carbohydrate amount and insulin
sensitivity
|
1 Iftar: Breaking the fast at sunset.; 2 Sahur:
Start of fasting at sunrise.
Insulin therapy during fasting
BOT – basal insulin-supported oral therapy
It is recommended to reduce the single basal insulin daily dose by 15 to
30% and to slowly adjust the dose during the fasting period
according to the glucose metabolism. Double administration of basal insulin
should be distributed as follows: the usual morning dose is administered at
Iftar (sunset) and the evening dosage at a 50% reduction should be
administered at Sahur (sunrise) [93]
[102].
Rapid or short-acting prandial/bolus insulin
The usual dosage is to be administered according to the carbohydrate source
at Iftar. The administration of insulin at midday should be omitted. At
Sahur, an initial dose reduction of 25 to 50% is recommended and the
dosage should be adjusted as needed. Functional insulin therapy (FIT) can be
derived from the above recommended dose adjustment of basal and prandial
insulins.
Mixed insulins
For single administration: administer usual dosage at Iftar. For double
administration: usual morning dosage at Iftar, reduce usual evening dosage
by 25–50% and administer at Sahur. In case of three
administrations: skip midday dose, otherwise administer as recommended for
two administrations and gradually adjust the dose. A dose titration (if
necessary, according to a prescribed plan) should be performed every three
days according to the glucose value. Close monitoring or consultation with
the doctor in charge or the diabetes team is recommended.
Insulin pump therapy
The basal rate should be reduced by 20–40% in the last 3 to
4 h of fasting. An increase of the basal dose by
0–30% is recommended shortly after Iftar. The bolus dose
should be administered depending on the carbohydrate amount consumed and the
respective insulin sensitivity.
Quitting the fasting
Each patient should be informed about the possibility of quitting the fast. In
particular, symptoms of hypoglycemia or hyperglycemia should be taken seriously and
reacted to accordingly. In case of an unforeseeable event or an acute complication
(e. g. acute illness, massive blood glucose derailment), fasting should be
interrupted immediately. Fasting can be ended by ingesting a liquid containing
carbohydrates or with solid food.
In the case of hypoglycemia with typical symptoms, prompt glucose measurement is
recommended after an appropriate intake of fast-acting carbohydrates.
In case of unclear symptoms of blood glucose derailment (unclear differentiation
between hypoglycemia and hyperglycemia) and refusal to break the fast, immediate
glucose measurement is recommended and should be reacted to according to the values
listed below.
All patients should interrupt fasting when [93]:
-
The glucose value is<70 mg/dl
(3.9 mmol/l)
-
Symptoms of hypoglycemia or an acute illness have occurred.
German Diabetes Association: Clinical Practice Guidelines This is a translation of
the DDG clinical practice guideline published in Diabetologie 2022; 17 (Suppl 2):
S411–S431 DOI 10.1055/a-1789-5460
