I will do my best to present it over 10 minutes and I will highlight the most significant or interested part relevant to this presentation in the time allowed. The full result will be again disclosed in the publication coming up soon. So these are my disclosures, none of them related to the current project. As we all know, fasting Ramadan during the month of Ramadan carries abrupt changes in mealtime and carries abrupt changes in lifestyle. And this is something we have recognized for a very long time. And this caused the patient with diabetes willing to fast a lot of disturbance in his or her lifestyle and a lot of problems or difficulties for the health care team how to deal with it. Islamic regulation exempted people who are identified as high risk from fasting or people who expected to endure high risk outcome just from performing fasting, they are also exempted from fasting. However, despite this exemption, many individuals with type 1 diabetes insist on fasting. So this led to collaboration between the International Diabetes Federation and the Diabetes and Ramadan International Alliance to draft and enhance guidelines and classification to help guide us as a health care worker or medical team and patient how to do with Ramadan and how to decide about fasting. So there is a need for practical validation studies to strengthen the evidence behind the IDF-DAR guidelines and to ensure the algorithm optimally managed individuals with diabetes observing Ramadan. So in this study, what we did, we aimed to evaluate the consistency of the IDF-DAR classification system in real world settings. And I emphasize real world settings, no intervention in patients with type 1 diabetes who fast or attempt to fast during Ramadan. This was a cross-sectional study for people with type 1 diabetes age 14 years and above residing in Saudi Arabia, and they were invited to participate in an online survey launched after Ramadan of 2022. Ramadan 2022 was in the month, took place April 1st to May 1st. So we launched this approximately 17 days after the end of Ramadan. Respondent were stratified according to the IDF-DAR guidelines, standardized online questionnaire consisted of three parts, demographic, medical history, aspect of diabetes management and some risk factors. The main variable of interest to us was risk factors related to breaking the fast, adherence to diabetes management during Ramadan and the outcome of having DKA or visiting ER. So let's dive into the result and I will start with table one. So overall we had 963 participants, 73% were female. We had also 325 individuals or participants categorized as intermediate risk. This represent about 33% and 638 an individual classified as having high risk. And this represent approximately 66%. Mean age 26 years old and mean BMI was 25, nothing different between the two groups. If we look at the diabetes duration, yes, there are some differences, more individuals in the high risk category have longer history of diabetes, this is expected. And more individuals in the high risk category reported more complication, namely retinopathy and nephropathy, otherwise the rest were similar between both groups. So if we go to the outcome related to Ramadan fasting and here we find some interesting results. So we had 77.8, so let's round it to 78% of this sample reported they attempted to fast. Now this is not far away from previous epidemiologic study in the region, goading how much or how many people with type 1 diabetes are willing to fast and it range in the 70s and some recent data showed even little bit higher number. However this is a high number, so the majority want to fast despite having type 1 diabetes, despite having the religious exemption. If we look who in the high versus moderate risk, we can see 75% among the high risk group reported attempting to fast. They want to fast, so this is the overwhelming majority attempting to fast. More 82% in the moderate risk group. If we see the number of days that they had to break their fast due to glucose problem, whether high or low, and these are represented in median, the high risk group had a median of 4 days of breaking their fast and this range between 1 and 10. The moderate had only 2 days and this range between 1 and 7. These are represented in median and we can see high risk group had to break their fast more days than the moderate risk group. Total number they completed fasting, how many days they fasted without any problem. The high risk group, again this is median number, is 21 and moderate risk group is 23. So the moderate risk group had more chance to fast more days than the high risk. If we look at the days absent from school or work due to diabetes during the month of Ramadan, and we ask them how many days did they have to not go to work or school. So the high risk group had more numbers. So 22% out of the high risk group reported not going to work or school for more than one day. While only 14% out of the moderate risk group reported not going for more than one day. Both are high but higher in the high risk group. If we look at DKA who was diagnosed with DKA during Ramadan, 11% out of the high risk group reported being diagnosed with DKA during Ramadan versus only 1.2% in the moderate risk group diagnosed with DKA. Same story with visiting ER due to diabetes related reasons, 13% in the high risk group visited ER, 4% only in the moderate risk group visited ER. Both were statistically different. If we see the reported days that they have to break their fast, two bars, your right side is the high risk group and your left is the moderate risk group, and the color coding category, so none, one to two days, yellow more than two days to four days, and red more than four days. So if we look at the high risk group, 46.6% of those in the high risk group reported breaking their fast more than four days versus only 34.9% in the moderate risk group. And it goes on. We have only 19% in the high risk group reported none, so they fasted all days versus 24% in the moderate. So more people in the moderate were able to complete their fasting than the high risk group. Okay, let's see differences in type one management, and there's a lot of interesting finding here. So let's look at the top part of the screen, and we'll start from your left side. So we asked if you were advised not to fast by your healthcare worker. So 38% of the high risk, red high risk, blue is moderate risk, 38% reported that they were actually advised by healthcare worker not to fast, and this is something excellent, that a little bit more than one third being contacted. But if you flip around and think differently, you can appreciate about 60% were not contacted and not advised to not fast Ramadan. Those are high risk, 60% were not contacted to give them the advice based on their risk scores. Moving forward, education, we asked how many session, or did you attend any educational session in the last 12 months? More so in the moderate six group, less in the high risk group. So again, this is gap in care provided, because a lot of emphasis, whether in diabetes guidelines in general or specifically for Ramadan, there is specification that education session helps to mitigate the risk and to emphasize importance of that. And I think this represents, again, another gap. Same story with visiting dietician, more in the intermediate risk group reported visiting dietician, less in the high risk group. And the last part is where you're contacted by your team, whether doctor, education, nurse education, it depends on the setting, to discuss insulin dosing during Ramadan. Only 33% of the high risk said yes, 45% of the moderate risk group say yes. Other way around, around 60 plus, 65% of the high risk did not receive guidance or a call from their physician or their medical care team to guide them on how to do their insulin dosing. Again, representing a gap in care somebody need to look at. Okay, on the bottom of the screen, I highlighted the significant part, which is using pump. More people in the moderate risk group were using insulin pump. Most pump are not the smart pump, not the hybrid closed loop pump. Most of them were VEO and 640, and they're not connected to the sensors, so they don't have the suspension feature. However, again, this is something we might look at if we think pump may help them while we are not providing it to the group that in most need for it. This carb count, again, the moderate reported higher number of people practicing carb count, and it goes with visiting the dietician and something that also is a gap in our care. Changing insulin dosage was similar, both high numbers, but again, this seems to me it was done by patient experience rather than doctor initiating this. The last result are multinomial logistic regression analysis that shows risk factor associated with breaking fast, and we can identify that patient using CGM patient with type 1 complication and patient fasting Ramadan for the first time, they're more likely to break their fast and worse relationship was noticed with age, male gender, being on injection, and contacted by HCP and changing insulin dose. This is a large sample, kingdom wide, so it provides some strength and it helps in the predictability of IDF DART tool in real world setting in Saudi Arabia. Keep in mind this is self-reported data, so bias, recall bias is there, and self-interpretation of the question is also there. They are from the patient point of view, and if you want to assess the care gap, we should have asked the HCP and the care managing team to participate to understand their view on the guidelines. I will finish with the conclusion, current risk factor, risk scoring is correct, and identified patients with risk factors who actually had more problems. People with type 1 actually fast, and there is a gap between the risk score and the care we provide. Thank you very much. Thanks for this opportunity.

type 1 diabetes

Ramadan fasting

IDF-DAR guidelines

health risks

patient safety