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  1. Introduction • Culture and religion play an important part in the life of many people across the world • In India, festivals hold a very important place • Majority of Indian festivals are considered to be synonymous with eating, feasting and gifting sweets • Our festivals have a special sweet/ savoury item associated with them, e.g., • Ramadan (with its famed falooda) • Diwali (mouth watering ladoos) • Ganesh Chaturthi (the ubiquitous modak) • Navratri (tender rasgullas) • Christmas (famous Christmas cakes) and the New Year (alcohol and high calorie food) are a few to mention

  2. Introduction Festivals not only include feasting and relishing tasty food but also have 'fasting' as an integral part This fasting during festivals can last from days to months depending on a person's religious faith Hindus fast during Vatapoornima, KarvaChauth, Janmashtami, Navratri, Mahashivratri, etc Jains practice Paryushan, Muslims fast during the holy month of Ramadan, Christians practice Lent, Buddhists also have Lent fasts Thus, most religious groups have fasting in their festival celebrations

  3. Impact of festivals on Diabetes Religio-cultural practices are an integral component of day-to-day activities and impact an individual's health as well Health cannot be ignored whether it is a fasting or a feasting occasion Meeting a balance between 'health' and 'celebrations' is a tight rope walk, especially for those with compromised health status Diabetics place an important challenge in this regard. Diabetes patients are often confronted with a dilemma if they should 'fast' or 'feast‘ The healthcare provider plays an important role in helping diabetes patients sail through the festival season by enjoying themselves without having an adverse impact on their health

  4. Impact of festivals on Diabetes Fasts are characterised by a well-documented impact on metabolic health in healthy individuals as well as in those with various metabolic abnormalities In diabetics, their blood sugar levels can significantly vary during festival days due to fasting, feasting or as a result of infrequent meals The medications, time of medications, insulin dosage, exercise schedules, dietary recommendations are all impacted by festival time

  5. Diabetic Complications During Festivals • The major contributors towards inadequately managed diabetes during festivals are: • A sudden change in dietary habits • Lack of monitoring • Disrupted medication • Some of the major potential diabetes-related complications of fasting and feasting include dangerously low blood glucose (hypoglycaemia), excessively high blood glucose (hyperglycaemia), Diabetic Ketoacidosis (DKA), and Hyperosmolar Hyperglycaemic State (HHS) • All of these complications are acute but serious complications in diabetes patients that manifest suddenly and insidiously

  6. Diabetic Complications During Festivals There is a significant increase in fasting and post-prandial plasma glucose, total cholesterol, triglycerides and very low-density lipoprotein (VLDL) cholesterol after Diwali Whereas, high-density lipoprotein (HDL) cholesterol is found to be reduced significantly It is observed that festivals like Diwali are associated with significant impairment in glycaemic control and lipid profile The other end of spectrum is fasting during Navratri by many devotees, which commonly extends beyond 24 hours and often lasts for several days, when even water is not allowed Such severe forms of extended fasting can lead to life-threatening complications in already uncontrolled diabetics

  7. Who Should Avoid Fasting During Festivals? Based on the observations during Ramadan, religious fasting in general is discouraged in patients with type 1 diabetes by various societies including the American Diabetes Association (ADA) Ritualistic fasting under peer and family pressure is often treated as a test of personal religious faith, resulting in unrealistic strict abstinence from all foods and drinks, including water This also includes stopping of all antidiabetic medications in patients with diabetes

  8. Who Should Avoid Fasting During Festivals?

  9. Causes of Diabetes related complications during festivals

  10. Causes of Diabetes related complications during festivals

  11. Category of patients at risk during festivals

  12. Hypoglycaemia Frequent hypoglycaemia leads to inability of recognising initial symptoms on subsequent episodes In individuals taking insulin and/or insulin secretagogues, fasting and strenuous physical activity can cause hypoglycaemia if medication dose or carbohydrate consumption is not altered

  13. Hypoglycaemia

  14. Practical Points For Physicians To Communicate With Patients Physicians should advise the patients that fasting should not be overdone, and fasting without adequate safeguards may predispose to hypoglycaemia, especially when the patient is also receiving glucose lowering medications Physicians should understand the patient's exact perspective of fasting, including duration of fast, and stress on allowance for liquids and snacks during the day, acceptance of sublingual foods and necessity to break the fast in case of significant discomfort Physicians should explain the importance of modification in pre-fast diet, hydration and medication change to the patient

  15. What Should The Physician Advise/ Do In Patients Who Are Adamant To Fast Pre-fast meal assumes importance and should provide complex carbohydrates with low glycaemic index and proteins like unprocessed cereals, fruits, nuts and lentils Adequate water and fluids must be taken prior to the fast, especially in cases where fluid intake will be restricted throughout the day Patients can perform routine daily activities easily, but elective moderateto- highly vigorous exercise should be avoided Modification in antidiabetic pharmacotherapy to meet the patient's requirements during the period of fasting is required

  16. What Should The Physician Advise/ Do In Patients Who Are Adamant To Fast

  17. Hyperglycemia

  18. Diabetic Ketoacidosis

  19. Diabetic Ketoacidosis

  20. Hyperosmolar Hyperglycemic state

  21. Hyperosmolar Hyperglycemic state

  22. Management of Diabetes related complications during festival

  23. Management of Diabetes related complications during festival

  24. Assessment of Diabetes patients before and during festivals

  25. Assessment of Diabetes patients before and during festivals PATIENT ADVICES When the fast is broken at sunset with large meals often high in fats and sugars, including fizzy drinks and fruit juices, it can lead to hyperglycaemia Patients need to be advised how to choose healthier options, such as diet drinks, which allow them to participate in the social occasion

  26. Assessment of Diabetes patients before and during festivals PATIENT ADVICES Patients require advice on timing and adjustment of insulin or oral medication doses to prevent hypoglycaemia It is essential that patients with type 1 diabetes continue with insulin, otherwise they may develop DKA, which can occur in the absence of insulin even without food intake As patients do not take anything orally during the fasting hours, it is important that they are advised to break their fast if they become hypoglycaemic They should carry glucose and personal identification details with them at all times

  27. Assessment of Diabetes patients before and during festivals PATIENT ADVICES Many people often do not take tablets or inject insulin during fasting hours, and some may not perform blood glucose tests because of mistaken interpretation of religious instruction Poor attendance at clinics during some festivals is common, as people tend to rest during the day

  28. Treatment related advise during festivals Type 1 Diabetes

  29. Treatment related advise during festivals Type 2 Diabetes

  30. Treatment related advise during festivals Type 2 Diabetes

  31. Pregnancy and Festivals Fasting during pregnancy is believed to carry a high risk of death and disability to both the foetus and the mother Some pregnant females with known diabetes (including gestational diabetes) insist on fasting These women constitute a high risk group and their management requires intensive care The issues already discussed concerning the management of type 1 diabetes and type 2 diabetes also apply to pregnant women, along with more frequent monitoring and insulin dose adjustment Pregnant women should be strongly advised not to fast

  32. References Kalra S, Bajaj S, Gupta Y, Agarwal P, et al. Fasts, feasts and festivals in diabetes-1: Glycemic management during Hindu fasts. Indian J EndocrinolMetab. 2015; 19(2): 198-203. Ibrahim MA. Managing diabetes during Ramadan. Diabetes Voice. 2007;52(2):19-22. Fatima J, Karoli R, Chandra A, et al. Ramadan fasting in patients with type 2 diabetes mellitus: Experience from a teaching hospital. Indian Journal of Endocrinology and Metabolism. 2012;16(2):323-324. Pathan MF, Sahay RK, Zargar AH, et al. South Asian Consensus Guideline: Use of insulin in diabetes during Ramadan. Indian Journal of Endocrinology and Metabolism. 2012; 16(4) :499-502 Hill J. Management of diabetes in South Asian communities in the UK. Nursing Standard. 2006;20(25):57-64. Levin ME, Pfeifer MA, editors. The uncomplicated guide to diabetes complications. 3"' ed. American Diabetes Association 2009. American Diabetes Association Standards of Medical Care in Diabetes. Diabetes Care. 2015;38(1 ):S1-S93.

  33. References Patel V, Morrissey J, Goenka N, et al. Diabetes care in the Hindu patient:cultural and clinical aspects. Br J Diabetes Vasc Dis. 2001; 1: 132-5. Mathur N, Mathur R, Rawtani J. Impairment in glycemic control and lipid profile during indian festival Diwali. Presentation Number: SAT-169, at The Endocrine Society's 94'h Annual Meeting and Expo, June 23-26, 2012 - Houston, TX. Date of Presentation: June 23"', 2012. Dutta D, Biswas K, Sharma M, et al. Managing diabetes during Navratris with special focus on Durga pujas. J Soc Health Diabetes. 2015;3(2):84-8. Jaleel MA, RazaSA, Fathima FN, et al. Ramadan and diabetes: As-Saum (The fasting). Indian J EndocrinolMetab. 2011 ;15(4):268-273. IDF module 2011. Module 4. Available at: Last accessed: 23"' June 2015.

  34. Thank You