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The effect of Ramadan focused education on patients with type 2 diabetes: A systematic review and meta-analysis

Open AccessPublished:March 17, 2020DOI:https://doi.org/10.1016/j.diabres.2020.108122

      Abstract

      Aim

      The aim of this systematic review and meta-analysis was to assess the effect of Ramadan focused education on clinical and metabolic parameters in patients with type 2 diabetes who fast during Ramadan.

      Methods

      Literature search was done in PubMed, Embase (Ovid), and the Cochrane Library. Quality assessment was done using the ROBINS-I and Cochrane tools for risk of bias and analyses were performed using RevMan version 5.1.

      Results

      From 770 records, 430 full text studies were assessed. After exclusions, the final quantitative analysis included 16 studies. Pre-Ramadan education was associated with a significant reduction in HbA1c (SMD −0.46, 95% CI −0.65 to −0.27P < 0.05) and LDL (SMD −0.09, 95% CI −0.13 to −0.04P < 0.05), an increase in TG (SMD 0.07, 95% CI −0.23 to 0.93P < 0.05) and weight (SMD 0.44, 95% CI 0.06 to 0.81P < 0.05) and no change in hypoglycemic events, BMI, TC, HDL or blood pressure (P > 0.05) during Ramadan.

      Conclusions

      This systematic review and meta-analysis shows that Ramadan-focused diabetes education leads to a decrease in HbA1c and LDL, but an increase in TG and weight during Ramadan. It also identifies a lack of head to head studies and limited observational studies with adequately assessed end-points.

      Keywords

      1. Introduction

      Ramadan fasting is one of the five pillars of Islam [
      • Alabbood M.H.
      • Ho K.W.
      • Simons M.R.
      The effect of Ramadan fasting on glycaemic control in insulin dependent diabetic patients: a literature review.
      ,

      International Diabetes Federation (IDF) icwtDaRDIA. Diabetes and Ramadan: Practical Guidelines 2016 [Available from: https://www.idf.org/e-library/guidelines/87-diabetes-and-ramadan-practical-25].

      ] and requires refraining from eating, drinking and the use of oral or parenteral medications from sunrise to sunset for 29–30 consecutive days once a year [
      • Alabbood M.H.
      • Ho K.W.
      • Simons M.R.
      The effect of Ramadan fasting on glycaemic control in insulin dependent diabetic patients: a literature review.
      ,
      • Abolaban H.
      • Al-Moujahed A.
      Muslim patients in Ramadan: A review for primary care physicians.
      ]. Ramadan fasting is not recommended for patients with Type 1 diabetes and a large proportion of patients with Type 2 diabetes [
      • Hassanein M.
      • Al-Arouj M.
      • Hamdy O.
      • Bebakar W.M.W.
      • Jabbar A.
      • Al-Madani A.
      • et al.
      Diabetes and ramadan: practical guidelines.
      ,
      • Bragazzi N.L.
      • Briki W.
      • Khabbache H.
      • Rammouz I.
      • Mnadla S.
      • Demaj T.
      • et al.
      Ramadan fasting and infectious diseases: a systematic review.
      ]. However, a recent survey of 38,000 patients with diabetes from 39 countries found that 39% fasted during Ramadan and the epidemiology of diabetes and Ramadan (EPIDIAR) study had also previously shown that 43% of patients with type 1 diabetes and 79% with type 2 diabetes fasted during Ramadan [
      • Adnan Z.
      Type 2 diabetic patients fasting on ramadan in israel.
      ,
      • Salti I.
      • Benard E.
      • Detournay B.
      • Bianchi-Biscay M.
      • Le Brigand C.
      • Voinet C.
      • et al.
      A population-based study of diabetes and its characteristics during the fasting month of Ramadan in 13 countries: results of the epidemiology of diabetes and Ramadan 1422/2001 (EPIDIAR) study.
      ]. Fasting may lead to medication non-adherence [
      • Abolaban H.
      • Al-Moujahed A.
      Muslim patients in Ramadan: A review for primary care physicians.
      ] and complications including dehydration, hyperglycemia, diabetic ketoacidosis (DKA) [
      • Alabbood M.H.
      • Ho K.W.
      • Simons M.R.
      The effect of Ramadan fasting on glycaemic control in insulin dependent diabetic patients: a literature review.
      ,
      • Abolaban H.
      • Al-Moujahed A.
      Muslim patients in Ramadan: A review for primary care physicians.
      ,
      • Adnan Z.
      Type 2 diabetic patients fasting on ramadan in israel.
      ] and hypoglycemia [
      • Jabbar A.
      • Hassanein M.
      • Beshyah S.A.
      • Boye K.S.
      • Yu M.
      • Babineaux S.M.
      CREED study: hypoglycaemia during Ramadan in individuals with Type 2 diabetes mellitus from three continents.
      ].
      While some studies have shown no impact of Ramadan fasting on metabolic parameters in patients with diabetes [
      • Bouguerra R.B.S.C.
      • Belkadhi A.
      • Jabrane H.
      • Beltaifa L.
      • Ben Rayana C.
      • et al.
      Metabolic control and plasma lipoprotein during Ramadan fasting in non-insulin-dependent diabetes.
      ,
      • Azizi F.S.B.
      Ramadan fasting and diabetes mellitus.
      ], other studies have shown an improvement in glycemia and lipids in those with good baseline control with worsening in patients with poor glycemic control [
      • Bouguerra R.
      • Jabrane J.
      • Maatki C.
      • Ben Salem L.
      • Hamzaoui J.
      • El Kadhi A.
      • et al.
      Ramadan fasting in type 2 diabetes mellitus.
      ]. Some studies have demonstrated a significant reduction [
      • Bravis V.
      • Hui E.
      • Salih S.
      • Mehar S.
      • Hassanein M.
      • Devendra D.
      Ramadan education and awareness in diabetes (READ) programme for Muslims with type 2 diabetes who fast during Ramadan.
      ,
      • McEwen L.N.
      • Ibrahim M.
      • Ali N.M.
      • Assaad-Khalil S.H.
      • Tantawi H.R.
      • Nasr G.
      • et al.
      Impact of an individualized type 2 diabetes education program on clinical outcomes during Ramadan.
      ] whilst others have shown no significant change in HbA1c, weight or BMI [
      • Ahmedani M.Y.
      • Alvi S.F.
      • Haque M.S.
      • Fawwad A.
      • Basit A.
      Implementation of Ramadan-specific diabetes management recommendations: a multi-centered prospective study from Pakistan.
      ,
      • Tourkmani A.M.
      • Hassali M.A.
      • Alharbi T.J.
      • Alkhashan H.I.
      • Alobikan A.H.
      • Bakhiet A.H.
      • et al.
      Impact of Ramadan focused education program on hypoglycemic risk and metabolic control for patients with type 2 diabetes.
      ].
      Educational programmes have shown a significant benefit in Type 1 diabetes [
      • Walker G.S.
      • Chen J.Y.
      • Hopkinson H.
      • Sainsbury C.A.R.
      • Jones G.C.
      Structured education using Dose Adjustment for Normal Eating (DAFNE) reduces long-term HbA1c and HbA1c variability.
      ] and to a lesser extent in Type 2 diabetes [
      • Al-Arouj M.
      • Assaad-Khalil S.
      • Buse J.
      • Fahdil I.
      • Fahmy M.
      • Hafez S.
      • et al.
      Recommendations for management of diabetes during Ramadan: update 2010.
      ,
      • Davies M.J.
      • Heller S.
      • Skinner T.C.
      • Campbell M.J.
      • Carey M.E.
      • Cradock S.
      • et al.
      Effectiveness of the diabetes education and self management for ongoing and newly diagnosed (DESMOND) programme for people with newly diagnosed type 2 diabetes: cluster randomised controlled trial.
      ]. Accordingly, recommendations have been made to provide Ramadan-focused education to all patients prior to Ramadan fasting [
      • Al-Arouj M.
      • Assaad-Khalil S.
      • Buse J.
      • Fahdil I.
      • Fahmy M.
      • Hafez S.
      • et al.
      Recommendations for management of diabetes during Ramadan: update 2010.
      ]. An early study showed a 50% reduction in hypoglycemic event rates [
      • Bravis V.
      • Hui E.
      • Salih S.
      • Mehar S.
      • Hassanein M.
      • Devendra D.
      Ramadan education and awareness in diabetes (READ) programme for Muslims with type 2 diabetes who fast during Ramadan.
      ] and weight loss [
      • Hassanein M.
      • Bravis V.
      • Hui E.
      • Devendra D.
      Ramadan-focused education and awareness in type 2 diabetes.
      ] with pre-Ramadan education. The diabetes education and medication adjustment in Ramadan (DEAR) program also showed a significant reduction in weight, BMI, HbA1c, LDL-C, triglycerides and hypoglycemic events [
      • Zainudin S.B.
      • Abu Bakar K.N.B.
      • Abdullah S.B.
      • Hussain A.B.
      Diabetes education and medication adjustment in Ramadan (DEAR) program prepares for self-management during fasting with tele-health support from pre-Ramadan to post-Ramadan.
      ]. This systematic review and meta-analysis provides an objective overall assessment of the benefits of Ramadan specific education [
      • Hassanein M.
      Ramadan focused diabetes education; a much needed approach.
      ].

      2. Methods

      The systematic review and meta-analysis is reported in accordance with PRISMA guidelines [

      The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) [updated October 2015; cited 2018 12 December 2018]. Available from: http://www.prisma-statement.org/.

      ]. The review protocol was registered with the International Prospective Register of Systematic Reviews (PROSPERO) on 9 November 2017 (CRD42017078057).

      2.1 Data sources and extraction

      Three databases were chosen to search for this systematic review: PubMed, Embase (Ovid), and the Cochrane Library. In the PubMed database and Cochrane Library; both MeSH subject headings and keywords were searched; in Embase Emtree subject headings and keywords were utilized. Numerous terms were tested for relevancy and the final search strings for the three databases can be found in. Article languages were limited to those in English and no date restrictions were set. A segment of the grey literature was searched through the use of Dissertation and Theses (ProQuest) and Conference Proceedings Citation Index- Science (CPCI-S) --1990-present / Conference Proceedings Citation Index- Social Science & Humanities (CPCI-SSH) --1990-present (Web of Science). The databases were searched from inception to November 2019. Citations resulting from the searches were all compiled into an EndNote library where they were de-duplicated. Citations were then uploaded into Covidence systematic review software where they were selected/deselected according to inclusion and exclusion criteria.
      We included observational studies that reported on HbA1c in patients with diabetes who fasted during Ramadan. Randomized controlled trials were also eligible. Studies with mixed populations (T1DM and T2DM) were included and only data on the T2DM group (where available) were extracted. Studies from any country and ethnic group were included. All study designs were included except literature reviews and systematic reviews, correspondence and newspaper articles. Studies were included if they reported on at least one of the following: HbA1c (%); fasting plasma glucose (mmol/L); pre-prandial glucose (mmol/L); postprandial glucose (mmol/L); weight (Kg); BMI (Kg/m2); neck (cm), waist (cm), hip circumference (cm); body fat mass (Kg); fat percent (%); lipid profile (total cholesterol; LDL-C; TG; HDL-C) (mmol/L); SBP/DBP (mmHg); fasting adverse events (hypoglycemia (number of patients with the event), DKA; HONK; DVT; hospital admission; emergency hospital visits); QoL; adherence to medication pre and post Ramadan or during-Ramadan and post-Ramadan. Studies were excluded if they reported on fasting for other religious or spiritual purposes and if reporting on the outcome was pre, during, or post Ramadan only.

      2.2 Study selection

      After removal of duplicates, all citations were screened for relevance using the full citation, abstract and indexing terms, before excluding studies deemed as not relevant. Where there was a lack of consensus a third author was consulted (RM). Duplicates were removed and the most recent and complete versions of the studies were reviewed for eligibility. Relevant studies were assessed by two reviewers (HG and HA) to assess eligibility according to the pre-specified inclusion and exclusion criteria. Possible full manuscripts of these potentially eligible citations were obtained. Two reviewers made the final inclusion and exclusion decisions independently. In case of disagreement, a third reviewer (RM) was consulted to resolve the conflicts. Hand searching of the list of references of the included studies was done by (HP) and reviewed by (HG). The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) flow chart of search results was produced (Fig. 1). A data extraction sheet was developed for extracting the data from each study. The data included specific details about the patients, exposure, setting and outcomes. Data extraction was done by two reviewers (HA and HP) and all included studies were double checked by the third reviewer (HG). In the event of missing data, authors were contacted by email or telephone in order to obtain the unpublished information in writing.

      2.3 Quality assessment

      Included studies were assessed using the Risk of Bias In Non-randomized Studies – on Interventions (ROBINS-I) tool [

      Sterne Jonathan AC HMA, Reeves Barnaby C, Savović Jelena, Berkman Nancy D, Viswanathan Meera et al. ROBINS-I: a tool for assessing risk of bias in non-randomised studies of interventions BMJ. 2016;355:i4919.

      ]. This tool categorizes the risk of bias as low, moderate, serious, critical, and unclear. The Cochrane Collaboration’s tool for assessing risk of bias was used for the randomized studies (Section 8.5) [

      Higgins JPT GSe. Cochrane Handbook for Systematic Reviews of Interventions.: John Wiley & Sons Ltd, the trium, Southern Gate, Chichester, West Sussex PO19 8SQ, Englnd, Telephone (+44) 1243 779777; 2017.

      ]. This tool assessed 6 domains: selection bias; performance bias; detection bias; attrition bias; reporting bias; and other bias. Quality assessment was undertaken by one reviewer and checked by a second reviewer and disagreements regarding the quality of a trial were resolved by consensus, or after consultation with the third reviewer (RM). If a study’s risk of bias was serious, critical or unclear, the effect of removing this study was checked and relevant outcomes were reported.

      2.4 Data synthesis and analysis

      Meta-analysis was performed in RevMan (version 5.3) [

      Community C. RevMan 5 [cited 2018 12 December 2018]. Available from: https://community.cochrane.org/help/tools-and-software/revman-5.

      ]. Random effects meta-analysis was used in anticipation of heterogeneity due to differences in study design and population. Standard mean differences (SMD) with 95% confidence intervals were calculated for the continuous variables; HbA1c, weight, lipid profile. Odds ratio (OR) with 95% confidence intervals was calculated to measure the effect of fasting on hypoglycemia. The I2 statistic was calculated, which is derived from Cochrane’s chi-squared test Q and is used to describe the percentage of between-study variations attributable to variability in the true exposure effect [
      • Higgins J.P.
      • Thompson S.G.
      • Deeks J.J.
      • Altman D.G.
      Measuring inconsistency in meta-analyses.
      ]. An I2 value of 0–30% was classified as not important, 31–60% as moderate, 61–90% as substantial, and 91–100% as considerable [
      • Deeks J.J.H.J.
      • Altman D.G.
      Analysing data and undertaking metaanalyses.
      ].

      3. Results

      The search strategy identified 770 records (Fig. 1). After removing duplicates, 719 papers were screened on the basis of their titles and abstracts, out of which 291 were excluded, resulting in 430 papers being assessed using their full text. After exclusions, 16 studies were included in the meta-analysis.
      Meta-analysis was undertaken on the following variables: HbA1c (%) included 9 studies in (2034 individuals) [
      • Bravis V.
      • Hui E.
      • Salih S.
      • Mehar S.
      • Hassanein M.
      • Devendra D.
      Ramadan education and awareness in diabetes (READ) programme for Muslims with type 2 diabetes who fast during Ramadan.
      ,
      • McEwen L.N.
      • Ibrahim M.
      • Ali N.M.
      • Assaad-Khalil S.H.
      • Tantawi H.R.
      • Nasr G.
      • et al.
      Impact of an individualized type 2 diabetes education program on clinical outcomes during Ramadan.
      ,
      • Tourkmani A.M.
      • Hassali M.A.
      • Alharbi T.J.
      • Alkhashan H.I.
      • Alobikan A.H.
      • Bakhiet A.H.
      • et al.
      Impact of Ramadan focused education program on hypoglycemic risk and metabolic control for patients with type 2 diabetes.
      ,
      • Zainudin S.B.
      • Abu Bakar K.N.B.
      • Abdullah S.B.
      • Hussain A.B.
      Diabetes education and medication adjustment in Ramadan (DEAR) program prepares for self-management during fasting with tele-health support from pre-Ramadan to post-Ramadan.
      ,
      • El Toony L.F.
      • Hamad D.A.
      • Omar O.M.
      Outcome of focused pre-Ramadan education on metabolic and glycaemic parameters in patients with type 2 diabetes mellitus.
      ,
      • Hassanein M.
      • Abdelgadir E.
      • Bashier A.
      • Rashid F.
      • Saeed M.A.
      • Khalifa A.
      • et al.
      The role of optimum diabetes care in form of Ramadan focused diabetes education, flash glucose monitoring system and pre-Ramadan dose adjustments in the safety of Ramadan fasting in high risk patients with diabetes.
      ,
      • Lum Z.K.
      • See Toh W.Y.
      • Lim S.M.
      • Rusli K.D.B.
      • Abdul Shakoor S.
      • Tsou K.Y.K.
      • et al.
      Development of a collaborative algorithm for the management of type 2 diabetes during ramadan: an anchor on empowerment.
      ,

      Jamoussi HBO, R.; Chaabouni, S.; Gamoudi, A.; Berriche, O.; Mahjoub, F.; Sebai, Amrouche, C. . Interest of the therapeutic education in patients with type 2 diabetes observing the fast of Ramadan. AJM. 2017;53(1):71-5.

      ,
      • Srulovici E.
      • Leventer-Roberts M.
      • Curtis B.
      • He X.
      • Hoshen M.
      • Rotem M.
      • et al.
      Effectiveness of managing diabetes during ramadan conversation map intervention: a difference-in-differences (self-comparison) design.
      ]; FBG (mmol/L) included 4 studies (1272 individuals) [
      • El Toony L.F.
      • Hamad D.A.
      • Omar O.M.
      Outcome of focused pre-Ramadan education on metabolic and glycaemic parameters in patients with type 2 diabetes mellitus.
      ,
      • Srulovici E.
      • Leventer-Roberts M.
      • Curtis B.
      • He X.
      • Hoshen M.
      • Rotem M.
      • et al.
      Effectiveness of managing diabetes during ramadan conversation map intervention: a difference-in-differences (self-comparison) design.
      ,
      • M'Guil M.
      • Ragala M.A.
      • El Guessabi L.
      • Fellat S.
      • Chraibi A.
      • Chabraoui L.
      • et al.
      Is Ramadan fasting safe in type 2 diabetic patients in view of the lack of significant effect of fasting on clinical and biochemical parameters, blood pressure, and glycemic control?.
      ,
      • Susilparat P.
      • Pattaraarchachai J.
      • Songchitsomboon S.
      • Ongroongruang S.
      Effectiveness of contextual education for self-management in Thai Muslims with type 2 diabetes mellitus during Ramadan.
      ]; weight (Kg) included 9 studies (1109 individuals) [
      • Bravis V.
      • Hui E.
      • Salih S.
      • Mehar S.
      • Hassanein M.
      • Devendra D.
      Ramadan education and awareness in diabetes (READ) programme for Muslims with type 2 diabetes who fast during Ramadan.
      ,
      • Ahmedani M.Y.
      • Alvi S.F.
      • Haque M.S.
      • Fawwad A.
      • Basit A.
      Implementation of Ramadan-specific diabetes management recommendations: a multi-centered prospective study from Pakistan.
      ,
      • Tourkmani A.M.
      • Hassali M.A.
      • Alharbi T.J.
      • Alkhashan H.I.
      • Alobikan A.H.
      • Bakhiet A.H.
      • et al.
      Impact of Ramadan focused education program on hypoglycemic risk and metabolic control for patients with type 2 diabetes.
      ,
      • Zainudin S.B.
      • Abu Bakar K.N.B.
      • Abdullah S.B.
      • Hussain A.B.
      Diabetes education and medication adjustment in Ramadan (DEAR) program prepares for self-management during fasting with tele-health support from pre-Ramadan to post-Ramadan.
      ,
      • El Toony L.F.
      • Hamad D.A.
      • Omar O.M.
      Outcome of focused pre-Ramadan education on metabolic and glycaemic parameters in patients with type 2 diabetes mellitus.
      ,
      • Hassanein M.
      • Abdelgadir E.
      • Bashier A.
      • Rashid F.
      • Saeed M.A.
      • Khalifa A.
      • et al.
      The role of optimum diabetes care in form of Ramadan focused diabetes education, flash glucose monitoring system and pre-Ramadan dose adjustments in the safety of Ramadan fasting in high risk patients with diabetes.
      ,

      Jamoussi HBO, R.; Chaabouni, S.; Gamoudi, A.; Berriche, O.; Mahjoub, F.; Sebai, Amrouche, C. . Interest of the therapeutic education in patients with type 2 diabetes observing the fast of Ramadan. AJM. 2017;53(1):71-5.

      ,
      • M'Guil M.
      • Ragala M.A.
      • El Guessabi L.
      • Fellat S.
      • Chraibi A.
      • Chabraoui L.
      • et al.
      Is Ramadan fasting safe in type 2 diabetic patients in view of the lack of significant effect of fasting on clinical and biochemical parameters, blood pressure, and glycemic control?.
      ,
      • Susilparat P.
      • Pattaraarchachai J.
      • Songchitsomboon S.
      • Ongroongruang S.
      Effectiveness of contextual education for self-management in Thai Muslims with type 2 diabetes mellitus during Ramadan.
      ]; BMI (Kg/m2) included 8 studies (1398 individuals) [
      • McEwen L.N.
      • Ibrahim M.
      • Ali N.M.
      • Assaad-Khalil S.H.
      • Tantawi H.R.
      • Nasr G.
      • et al.
      Impact of an individualized type 2 diabetes education program on clinical outcomes during Ramadan.
      ,
      • Ahmedani M.Y.
      • Alvi S.F.
      • Haque M.S.
      • Fawwad A.
      • Basit A.
      Implementation of Ramadan-specific diabetes management recommendations: a multi-centered prospective study from Pakistan.
      ,
      • Tourkmani A.M.
      • Hassali M.A.
      • Alharbi T.J.
      • Alkhashan H.I.
      • Alobikan A.H.
      • Bakhiet A.H.
      • et al.
      Impact of Ramadan focused education program on hypoglycemic risk and metabolic control for patients with type 2 diabetes.
      ,
      • Zainudin S.B.
      • Abu Bakar K.N.B.
      • Abdullah S.B.
      • Hussain A.B.
      Diabetes education and medication adjustment in Ramadan (DEAR) program prepares for self-management during fasting with tele-health support from pre-Ramadan to post-Ramadan.
      ,
      • El Toony L.F.
      • Hamad D.A.
      • Omar O.M.
      Outcome of focused pre-Ramadan education on metabolic and glycaemic parameters in patients with type 2 diabetes mellitus.
      ,

      Jamoussi HBO, R.; Chaabouni, S.; Gamoudi, A.; Berriche, O.; Mahjoub, F.; Sebai, Amrouche, C. . Interest of the therapeutic education in patients with type 2 diabetes observing the fast of Ramadan. AJM. 2017;53(1):71-5.

      ,
      • M'Guil M.
      • Ragala M.A.
      • El Guessabi L.
      • Fellat S.
      • Chraibi A.
      • Chabraoui L.
      • et al.
      Is Ramadan fasting safe in type 2 diabetic patients in view of the lack of significant effect of fasting on clinical and biochemical parameters, blood pressure, and glycemic control?.
      ,
      • Susilparat P.
      • Pattaraarchachai J.
      • Songchitsomboon S.
      • Ongroongruang S.
      Effectiveness of contextual education for self-management in Thai Muslims with type 2 diabetes mellitus during Ramadan.
      ]; waist circumference (cm) included 2 studies (508 individuals) [
      • Ahmedani M.Y.
      • Alvi S.F.
      • Haque M.S.
      • Fawwad A.
      • Basit A.
      Implementation of Ramadan-specific diabetes management recommendations: a multi-centered prospective study from Pakistan.
      ,
      • El Toony L.F.
      • Hamad D.A.
      • Omar O.M.
      Outcome of focused pre-Ramadan education on metabolic and glycaemic parameters in patients with type 2 diabetes mellitus.
      ]; total cholesterol (mmol/L) included 5 studies (575 individuals) [
      • Tourkmani A.M.
      • Hassali M.A.
      • Alharbi T.J.
      • Alkhashan H.I.
      • Alobikan A.H.
      • Bakhiet A.H.
      • et al.
      Impact of Ramadan focused education program on hypoglycemic risk and metabolic control for patients with type 2 diabetes.
      ,
      • El Toony L.F.
      • Hamad D.A.
      • Omar O.M.
      Outcome of focused pre-Ramadan education on metabolic and glycaemic parameters in patients with type 2 diabetes mellitus.
      ,
      • Hassanein M.
      • Abdelgadir E.
      • Bashier A.
      • Rashid F.
      • Saeed M.A.
      • Khalifa A.
      • et al.
      The role of optimum diabetes care in form of Ramadan focused diabetes education, flash glucose monitoring system and pre-Ramadan dose adjustments in the safety of Ramadan fasting in high risk patients with diabetes.
      ,

      Jamoussi HBO, R.; Chaabouni, S.; Gamoudi, A.; Berriche, O.; Mahjoub, F.; Sebai, Amrouche, C. . Interest of the therapeutic education in patients with type 2 diabetes observing the fast of Ramadan. AJM. 2017;53(1):71-5.

      ,
      • M'Guil M.
      • Ragala M.A.
      • El Guessabi L.
      • Fellat S.
      • Chraibi A.
      • Chabraoui L.
      • et al.
      Is Ramadan fasting safe in type 2 diabetic patients in view of the lack of significant effect of fasting on clinical and biochemical parameters, blood pressure, and glycemic control?.
      ]; LDL-C (mmol/L) (1359 individuals) and TG (mmol/L) (1462 individuals) included 7 studies [
      • Tourkmani A.M.
      • Hassali M.A.
      • Alharbi T.J.
      • Alkhashan H.I.
      • Alobikan A.H.
      • Bakhiet A.H.
      • et al.
      Impact of Ramadan focused education program on hypoglycemic risk and metabolic control for patients with type 2 diabetes.
      ,
      • Zainudin S.B.
      • Abu Bakar K.N.B.
      • Abdullah S.B.
      • Hussain A.B.
      Diabetes education and medication adjustment in Ramadan (DEAR) program prepares for self-management during fasting with tele-health support from pre-Ramadan to post-Ramadan.
      ,
      • El Toony L.F.
      • Hamad D.A.
      • Omar O.M.
      Outcome of focused pre-Ramadan education on metabolic and glycaemic parameters in patients with type 2 diabetes mellitus.
      ,
      • Hassanein M.
      • Abdelgadir E.
      • Bashier A.
      • Rashid F.
      • Saeed M.A.
      • Khalifa A.
      • et al.
      The role of optimum diabetes care in form of Ramadan focused diabetes education, flash glucose monitoring system and pre-Ramadan dose adjustments in the safety of Ramadan fasting in high risk patients with diabetes.
      ,

      Jamoussi HBO, R.; Chaabouni, S.; Gamoudi, A.; Berriche, O.; Mahjoub, F.; Sebai, Amrouche, C. . Interest of the therapeutic education in patients with type 2 diabetes observing the fast of Ramadan. AJM. 2017;53(1):71-5.

      ,
      • Srulovici E.
      • Leventer-Roberts M.
      • Curtis B.
      • He X.
      • Hoshen M.
      • Rotem M.
      • et al.
      Effectiveness of managing diabetes during ramadan conversation map intervention: a difference-in-differences (self-comparison) design.
      ,
      • M'Guil M.
      • Ragala M.A.
      • El Guessabi L.
      • Fellat S.
      • Chraibi A.
      • Chabraoui L.
      • et al.
      Is Ramadan fasting safe in type 2 diabetic patients in view of the lack of significant effect of fasting on clinical and biochemical parameters, blood pressure, and glycemic control?.
      ], HDL-C (mmol/L) included 6 studies (602 individuals) [
      • Tourkmani A.M.
      • Hassali M.A.
      • Alharbi T.J.
      • Alkhashan H.I.
      • Alobikan A.H.
      • Bakhiet A.H.
      • et al.
      Impact of Ramadan focused education program on hypoglycemic risk and metabolic control for patients with type 2 diabetes.
      ,
      • Zainudin S.B.
      • Abu Bakar K.N.B.
      • Abdullah S.B.
      • Hussain A.B.
      Diabetes education and medication adjustment in Ramadan (DEAR) program prepares for self-management during fasting with tele-health support from pre-Ramadan to post-Ramadan.
      ,
      • El Toony L.F.
      • Hamad D.A.
      • Omar O.M.
      Outcome of focused pre-Ramadan education on metabolic and glycaemic parameters in patients with type 2 diabetes mellitus.
      ,
      • Hassanein M.
      • Abdelgadir E.
      • Bashier A.
      • Rashid F.
      • Saeed M.A.
      • Khalifa A.
      • et al.
      The role of optimum diabetes care in form of Ramadan focused diabetes education, flash glucose monitoring system and pre-Ramadan dose adjustments in the safety of Ramadan fasting in high risk patients with diabetes.
      ,

      Jamoussi HBO, R.; Chaabouni, S.; Gamoudi, A.; Berriche, O.; Mahjoub, F.; Sebai, Amrouche, C. . Interest of the therapeutic education in patients with type 2 diabetes observing the fast of Ramadan. AJM. 2017;53(1):71-5.

      ,
      • M'Guil M.
      • Ragala M.A.
      • El Guessabi L.
      • Fellat S.
      • Chraibi A.
      • Chabraoui L.
      • et al.
      Is Ramadan fasting safe in type 2 diabetic patients in view of the lack of significant effect of fasting on clinical and biochemical parameters, blood pressure, and glycemic control?.
      ]; SBP and DBP (mmHg) included 6 studies (999 individuals) [
      • Ahmedani M.Y.
      • Alvi S.F.
      • Haque M.S.
      • Fawwad A.
      • Basit A.
      Implementation of Ramadan-specific diabetes management recommendations: a multi-centered prospective study from Pakistan.
      ,
      • Tourkmani A.M.
      • Hassali M.A.
      • Alharbi T.J.
      • Alkhashan H.I.
      • Alobikan A.H.
      • Bakhiet A.H.
      • et al.
      Impact of Ramadan focused education program on hypoglycemic risk and metabolic control for patients with type 2 diabetes.
      ,
      • El Toony L.F.
      • Hamad D.A.
      • Omar O.M.
      Outcome of focused pre-Ramadan education on metabolic and glycaemic parameters in patients with type 2 diabetes mellitus.
      ,
      • Hassanein M.
      • Abdelgadir E.
      • Bashier A.
      • Rashid F.
      • Saeed M.A.
      • Khalifa A.
      • et al.
      The role of optimum diabetes care in form of Ramadan focused diabetes education, flash glucose monitoring system and pre-Ramadan dose adjustments in the safety of Ramadan fasting in high risk patients with diabetes.
      ,
      • M'Guil M.
      • Ragala M.A.
      • El Guessabi L.
      • Fellat S.
      • Chraibi A.
      • Chabraoui L.
      • et al.
      Is Ramadan fasting safe in type 2 diabetic patients in view of the lack of significant effect of fasting on clinical and biochemical parameters, blood pressure, and glycemic control?.
      ,
      • Susilparat P.
      • Pattaraarchachai J.
      • Songchitsomboon S.
      • Ongroongruang S.
      Effectiveness of contextual education for self-management in Thai Muslims with type 2 diabetes mellitus during Ramadan.
      ]; hypoglycemia (number of patients/total sample) included 2 studies (84 individuals) [
      • Bravis V.
      • Hui E.
      • Salih S.
      • Mehar S.
      • Hassanein M.
      • Devendra D.
      Ramadan education and awareness in diabetes (READ) programme for Muslims with type 2 diabetes who fast during Ramadan.
      ,
      • Zainudin S.B.
      • Abu Bakar K.N.B.
      • Abdullah S.B.
      • Hussain A.B.
      Diabetes education and medication adjustment in Ramadan (DEAR) program prepares for self-management during fasting with tele-health support from pre-Ramadan to post-Ramadan.
      ].

      3.1 Study characteristics

      Studies were conducted in different geographical locations; Saudi Arabia [
      • Tourkmani A.M.
      • Hassali M.A.
      • Alharbi T.J.
      • Alkhashan H.I.
      • Alobikan A.H.
      • Bakhiet A.H.
      • et al.
      Impact of Ramadan focused education program on hypoglycemic risk and metabolic control for patients with type 2 diabetes.
      ,

      Tourkmani AA, T. ; Bin Rsheed, A.; AlRasheed, A.; AlBattal, S.; Abdelhay, O.; Hassali, M.; Fayaa, S.; Assiri, E.; Al Ghishiayan, K.; Alrasheedy, A.; Abbas, M. Impact of Ramadan Focused Education Program on medications adjustment for patients with type 2 diabetes in a primary health care institution in Saudi Arabia. Diabetes & Metabolic Syndrome: Clinical Research & Reviews. 2019;13(1):161-5.

      ], United Arab Emirates [
      • Hassanein M.
      • Abdelgadir E.
      • Bashier A.
      • Rashid F.
      • Saeed M.A.
      • Khalifa A.
      • et al.
      The role of optimum diabetes care in form of Ramadan focused diabetes education, flash glucose monitoring system and pre-Ramadan dose adjustments in the safety of Ramadan fasting in high risk patients with diabetes.
      ]; Pakistan [
      • Ahmedani M.Y.
      • Alvi S.F.
      • Haque M.S.
      • Fawwad A.
      • Basit A.
      Implementation of Ramadan-specific diabetes management recommendations: a multi-centered prospective study from Pakistan.
      ,
      • Ahmadani M.Y.
      • Riaz M.
      • Fawwad A.
      • Hydrie M.Z.
      • Hakeem R.
      • Basit A.
      Glycaemic trend during Ramadan in fasting diabetic subjects: a study from Pakistan.
      ,
      • Ahmedani M.Y.
      • Haque M.S.
      • Basit A.
      • Fawwad A.
      • Alvi S.F.
      Ramadan prospective diabetes study: the role of drug dosage and timing alteration, active glucose monitoring and patient education.
      ,
      • Ahmedani M.Y.
      • Ahsan S.
      • Haque M.S.U.
      Role of Ramadan specific diabetes education (RSDE); a prospective study.
      ]; Thailand [
      • Susilparat P.
      • Pattaraarchachai J.
      • Songchitsomboon S.
      • Ongroongruang S.
      Effectiveness of contextual education for self-management in Thai Muslims with type 2 diabetes mellitus during Ramadan.
      ]; Singapore [
      • Zainudin S.B.
      • Abu Bakar K.N.B.
      • Abdullah S.B.
      • Hussain A.B.
      Diabetes education and medication adjustment in Ramadan (DEAR) program prepares for self-management during fasting with tele-health support from pre-Ramadan to post-Ramadan.
      ,
      • Lum Z.K.
      • See Toh W.Y.
      • Lim S.M.
      • Rusli K.D.B.
      • Abdul Shakoor S.
      • Tsou K.Y.K.
      • et al.
      Development of a collaborative algorithm for the management of type 2 diabetes during ramadan: an anchor on empowerment.
      ]; Jordan [
      • Khatib F.A.
      • Shafagoj Y.A.
      Metabolic alterations as a result of Ramadan fasting in non-insulin-dependent diabetes mellitus patients in relation to food intake.
      ]; Egypt [
      • El Toony L.F.
      • Hamad D.A.
      • Omar O.M.
      Outcome of focused pre-Ramadan education on metabolic and glycaemic parameters in patients with type 2 diabetes mellitus.
      ,
      • Eid Y.M.
      • Sahmoud S.I.
      • Abdelsalam M.M.
      • Eichorst B.
      Empowerment-based diabetes self-management education to maintain glycemic targets during ramadan fasting in people with diabetes who are on conventional insulin: a feasibility study.
      ]; Morocco [
      • M'Guil M.
      • Ragala M.A.
      • El Guessabi L.
      • Fellat S.
      • Chraibi A.
      • Chabraoui L.
      • et al.
      Is Ramadan fasting safe in type 2 diabetic patients in view of the lack of significant effect of fasting on clinical and biochemical parameters, blood pressure, and glycemic control?.
      ]; Tunisia [

      Jamoussi HBO, R.; Chaabouni, S.; Gamoudi, A.; Berriche, O.; Mahjoub, F.; Sebai, Amrouche, C. . Interest of the therapeutic education in patients with type 2 diabetes observing the fast of Ramadan. AJM. 2017;53(1):71-5.

      ] and United Kingdom [
      • Bravis V.
      • Hui E.
      • Salih S.
      • Mehar S.
      • Hassanein M.
      • Devendra D.
      Ramadan education and awareness in diabetes (READ) programme for Muslims with type 2 diabetes who fast during Ramadan.
      ]. A multi-center study from Egypt; Iran; Jordan; Saudi Arabia and USA was included in this review [
      • McEwen L.N.
      • Ibrahim M.
      • Ali N.M.
      • Assaad-Khalil S.H.
      • Tantawi H.R.
      • Nasr G.
      • et al.
      Impact of an individualized type 2 diabetes education program on clinical outcomes during Ramadan.
      ]. Four studies were of prospective non-randomized interventional controlled design [
      • Tourkmani A.M.
      • Hassali M.A.
      • Alharbi T.J.
      • Alkhashan H.I.
      • Alobikan A.H.
      • Bakhiet A.H.
      • et al.
      Impact of Ramadan focused education program on hypoglycemic risk and metabolic control for patients with type 2 diabetes.
      ,
      • El Toony L.F.
      • Hamad D.A.
      • Omar O.M.
      Outcome of focused pre-Ramadan education on metabolic and glycaemic parameters in patients with type 2 diabetes mellitus.
      ,
      • Hassanein M.
      • Abdelgadir E.
      • Bashier A.
      • Rashid F.
      • Saeed M.A.
      • Khalifa A.
      • et al.
      The role of optimum diabetes care in form of Ramadan focused diabetes education, flash glucose monitoring system and pre-Ramadan dose adjustments in the safety of Ramadan fasting in high risk patients with diabetes.
      ,

      Tourkmani AA, T. ; Bin Rsheed, A.; AlRasheed, A.; AlBattal, S.; Abdelhay, O.; Hassali, M.; Fayaa, S.; Assiri, E.; Al Ghishiayan, K.; Alrasheedy, A.; Abbas, M. Impact of Ramadan Focused Education Program on medications adjustment for patients with type 2 diabetes in a primary health care institution in Saudi Arabia. Diabetes & Metabolic Syndrome: Clinical Research & Reviews. 2019;13(1):161-5.

      ]; seven of prospective observational design [
      • McEwen L.N.
      • Ibrahim M.
      • Ali N.M.
      • Assaad-Khalil S.H.
      • Tantawi H.R.
      • Nasr G.
      • et al.
      Impact of an individualized type 2 diabetes education program on clinical outcomes during Ramadan.
      ,
      • Ahmedani M.Y.
      • Alvi S.F.
      • Haque M.S.
      • Fawwad A.
      • Basit A.
      Implementation of Ramadan-specific diabetes management recommendations: a multi-centered prospective study from Pakistan.
      ,

      Jamoussi HBO, R.; Chaabouni, S.; Gamoudi, A.; Berriche, O.; Mahjoub, F.; Sebai, Amrouche, C. . Interest of the therapeutic education in patients with type 2 diabetes observing the fast of Ramadan. AJM. 2017;53(1):71-5.

      ,
      • M'Guil M.
      • Ragala M.A.
      • El Guessabi L.
      • Fellat S.
      • Chraibi A.
      • Chabraoui L.
      • et al.
      Is Ramadan fasting safe in type 2 diabetic patients in view of the lack of significant effect of fasting on clinical and biochemical parameters, blood pressure, and glycemic control?.
      ,
      • Ahmedani M.Y.
      • Haque M.S.
      • Basit A.
      • Fawwad A.
      • Alvi S.F.
      Ramadan prospective diabetes study: the role of drug dosage and timing alteration, active glucose monitoring and patient education.
      ,
      • Khatib F.A.
      • Shafagoj Y.A.
      Metabolic alterations as a result of Ramadan fasting in non-insulin-dependent diabetes mellitus patients in relation to food intake.
      ,
      • Eid Y.M.
      • Sahmoud S.I.
      • Abdelsalam M.M.
      • Eichorst B.
      Empowerment-based diabetes self-management education to maintain glycemic targets during ramadan fasting in people with diabetes who are on conventional insulin: a feasibility study.
      ]; two of retrospective observational design [
      • Bravis V.
      • Hui E.
      • Salih S.
      • Mehar S.
      • Hassanein M.
      • Devendra D.
      Ramadan education and awareness in diabetes (READ) programme for Muslims with type 2 diabetes who fast during Ramadan.
      ,
      • Ahmadani M.Y.
      • Riaz M.
      • Fawwad A.
      • Hydrie M.Z.
      • Hakeem R.
      • Basit A.
      Glycaemic trend during Ramadan in fasting diabetic subjects: a study from Pakistan.
      ]; one quasi-experimental study [
      • Susilparat P.
      • Pattaraarchachai J.
      • Songchitsomboon S.
      • Ongroongruang S.
      Effectiveness of contextual education for self-management in Thai Muslims with type 2 diabetes mellitus during Ramadan.
      ]; one randomized controlled trial [
      • Lum Z.K.
      • See Toh W.Y.
      • Lim S.M.
      • Rusli K.D.B.
      • Abdul Shakoor S.
      • Tsou K.Y.K.
      • et al.
      Development of a collaborative algorithm for the management of type 2 diabetes during ramadan: an anchor on empowerment.
      ] and one of cross sectional design [
      • Zainudin S.B.
      • Abu Bakar K.N.B.
      • Abdullah S.B.
      • Hussain A.B.
      Diabetes education and medication adjustment in Ramadan (DEAR) program prepares for self-management during fasting with tele-health support from pre-Ramadan to post-Ramadan.
      ]. Ten studies targeted patients with type 2 diabetes only [
      • Bravis V.
      • Hui E.
      • Salih S.
      • Mehar S.
      • Hassanein M.
      • Devendra D.
      Ramadan education and awareness in diabetes (READ) programme for Muslims with type 2 diabetes who fast during Ramadan.
      ,
      • McEwen L.N.
      • Ibrahim M.
      • Ali N.M.
      • Assaad-Khalil S.H.
      • Tantawi H.R.
      • Nasr G.
      • et al.
      Impact of an individualized type 2 diabetes education program on clinical outcomes during Ramadan.
      ,
      • Tourkmani A.M.
      • Hassali M.A.
      • Alharbi T.J.
      • Alkhashan H.I.
      • Alobikan A.H.
      • Bakhiet A.H.
      • et al.
      Impact of Ramadan focused education program on hypoglycemic risk and metabolic control for patients with type 2 diabetes.
      ,
      • El Toony L.F.
      • Hamad D.A.
      • Omar O.M.
      Outcome of focused pre-Ramadan education on metabolic and glycaemic parameters in patients with type 2 diabetes mellitus.
      ,
      • Lum Z.K.
      • See Toh W.Y.
      • Lim S.M.
      • Rusli K.D.B.
      • Abdul Shakoor S.
      • Tsou K.Y.K.
      • et al.
      Development of a collaborative algorithm for the management of type 2 diabetes during ramadan: an anchor on empowerment.
      ,

      Jamoussi HBO, R.; Chaabouni, S.; Gamoudi, A.; Berriche, O.; Mahjoub, F.; Sebai, Amrouche, C. . Interest of the therapeutic education in patients with type 2 diabetes observing the fast of Ramadan. AJM. 2017;53(1):71-5.

      ,
      • M'Guil M.
      • Ragala M.A.
      • El Guessabi L.
      • Fellat S.
      • Chraibi A.
      • Chabraoui L.
      • et al.
      Is Ramadan fasting safe in type 2 diabetic patients in view of the lack of significant effect of fasting on clinical and biochemical parameters, blood pressure, and glycemic control?.
      ,
      • Susilparat P.
      • Pattaraarchachai J.
      • Songchitsomboon S.
      • Ongroongruang S.
      Effectiveness of contextual education for self-management in Thai Muslims with type 2 diabetes mellitus during Ramadan.
      ,

      Tourkmani AA, T. ; Bin Rsheed, A.; AlRasheed, A.; AlBattal, S.; Abdelhay, O.; Hassali, M.; Fayaa, S.; Assiri, E.; Al Ghishiayan, K.; Alrasheedy, A.; Abbas, M. Impact of Ramadan Focused Education Program on medications adjustment for patients with type 2 diabetes in a primary health care institution in Saudi Arabia. Diabetes & Metabolic Syndrome: Clinical Research & Reviews. 2019;13(1):161-5.

      ,
      • Khatib F.A.
      • Shafagoj Y.A.
      Metabolic alterations as a result of Ramadan fasting in non-insulin-dependent diabetes mellitus patients in relation to food intake.
      ]; 4 studies targeted type 1 diabetes and type 2 diabetes [
      • Ahmedani M.Y.
      • Alvi S.F.
      • Haque M.S.
      • Fawwad A.
      • Basit A.
      Implementation of Ramadan-specific diabetes management recommendations: a multi-centered prospective study from Pakistan.
      ,
      • Zainudin S.B.
      • Abu Bakar K.N.B.
      • Abdullah S.B.
      • Hussain A.B.
      Diabetes education and medication adjustment in Ramadan (DEAR) program prepares for self-management during fasting with tele-health support from pre-Ramadan to post-Ramadan.
      ,
      • Ahmadani M.Y.
      • Riaz M.
      • Fawwad A.
      • Hydrie M.Z.
      • Hakeem R.
      • Basit A.
      Glycaemic trend during Ramadan in fasting diabetic subjects: a study from Pakistan.
      ,
      • Ahmedani M.Y.
      • Haque M.S.
      • Basit A.
      • Fawwad A.
      • Alvi S.F.
      Ramadan prospective diabetes study: the role of drug dosage and timing alteration, active glucose monitoring and patient education.
      ,
      • Eid Y.M.
      • Sahmoud S.I.
      • Abdelsalam M.M.
      • Eichorst B.
      Empowerment-based diabetes self-management education to maintain glycemic targets during ramadan fasting in people with diabetes who are on conventional insulin: a feasibility study.
      ]; 1 study targeted high-risk patients including those with type 1, type 2, gestational diabetes, previous cardiovascular diseases and chronic kidney disease [
      • Hassanein M.
      • Abdelgadir E.
      • Bashier A.
      • Rashid F.
      • Saeed M.A.
      • Khalifa A.
      • et al.
      The role of optimum diabetes care in form of Ramadan focused diabetes education, flash glucose monitoring system and pre-Ramadan dose adjustments in the safety of Ramadan fasting in high risk patients with diabetes.
      ]. Nine studies reported on HbA1c at two time-points [
      • Bravis V.
      • Hui E.
      • Salih S.
      • Mehar S.
      • Hassanein M.
      • Devendra D.
      Ramadan education and awareness in diabetes (READ) programme for Muslims with type 2 diabetes who fast during Ramadan.
      ,
      • McEwen L.N.
      • Ibrahim M.
      • Ali N.M.
      • Assaad-Khalil S.H.
      • Tantawi H.R.
      • Nasr G.
      • et al.
      Impact of an individualized type 2 diabetes education program on clinical outcomes during Ramadan.
      ,
      • Tourkmani A.M.
      • Hassali M.A.
      • Alharbi T.J.
      • Alkhashan H.I.
      • Alobikan A.H.
      • Bakhiet A.H.
      • et al.
      Impact of Ramadan focused education program on hypoglycemic risk and metabolic control for patients with type 2 diabetes.
      ,
      • Zainudin S.B.
      • Abu Bakar K.N.B.
      • Abdullah S.B.
      • Hussain A.B.
      Diabetes education and medication adjustment in Ramadan (DEAR) program prepares for self-management during fasting with tele-health support from pre-Ramadan to post-Ramadan.
      ,
      • El Toony L.F.
      • Hamad D.A.
      • Omar O.M.
      Outcome of focused pre-Ramadan education on metabolic and glycaemic parameters in patients with type 2 diabetes mellitus.
      ,
      • Hassanein M.
      • Abdelgadir E.
      • Bashier A.
      • Rashid F.
      • Saeed M.A.
      • Khalifa A.
      • et al.
      The role of optimum diabetes care in form of Ramadan focused diabetes education, flash glucose monitoring system and pre-Ramadan dose adjustments in the safety of Ramadan fasting in high risk patients with diabetes.
      ,
      • Lum Z.K.
      • See Toh W.Y.
      • Lim S.M.
      • Rusli K.D.B.
      • Abdul Shakoor S.
      • Tsou K.Y.K.
      • et al.
      Development of a collaborative algorithm for the management of type 2 diabetes during ramadan: an anchor on empowerment.
      ,

      Jamoussi HBO, R.; Chaabouni, S.; Gamoudi, A.; Berriche, O.; Mahjoub, F.; Sebai, Amrouche, C. . Interest of the therapeutic education in patients with type 2 diabetes observing the fast of Ramadan. AJM. 2017;53(1):71-5.

      ,
      • Khatib F.A.
      • Shafagoj Y.A.
      Metabolic alterations as a result of Ramadan fasting in non-insulin-dependent diabetes mellitus patients in relation to food intake.
      ], while 6 studies reported on HbA1c either pre-Ramadan [
      • Ahmedani M.Y.
      • Alvi S.F.
      • Haque M.S.
      • Fawwad A.
      • Basit A.
      Implementation of Ramadan-specific diabetes management recommendations: a multi-centered prospective study from Pakistan.
      ,
      • M'Guil M.
      • Ragala M.A.
      • El Guessabi L.
      • Fellat S.
      • Chraibi A.
      • Chabraoui L.
      • et al.
      Is Ramadan fasting safe in type 2 diabetic patients in view of the lack of significant effect of fasting on clinical and biochemical parameters, blood pressure, and glycemic control?.
      ,
      • Susilparat P.
      • Pattaraarchachai J.
      • Songchitsomboon S.
      • Ongroongruang S.
      Effectiveness of contextual education for self-management in Thai Muslims with type 2 diabetes mellitus during Ramadan.
      ,
      • Ahmedani M.Y.
      • Haque M.S.
      • Basit A.
      • Fawwad A.
      • Alvi S.F.
      Ramadan prospective diabetes study: the role of drug dosage and timing alteration, active glucose monitoring and patient education.
      ,
      • Eid Y.M.
      • Sahmoud S.I.
      • Abdelsalam M.M.
      • Eichorst B.
      Empowerment-based diabetes self-management education to maintain glycemic targets during ramadan fasting in people with diabetes who are on conventional insulin: a feasibility study.
      ] or during Ramadan [
      • Ahmadani M.Y.
      • Riaz M.
      • Fawwad A.
      • Hydrie M.Z.
      • Hakeem R.
      • Basit A.
      Glycaemic trend during Ramadan in fasting diabetic subjects: a study from Pakistan.
      ]. Tourkmani et al did not report on HbA1c at any time point [

      Tourkmani AA, T. ; Bin Rsheed, A.; AlRasheed, A.; AlBattal, S.; Abdelhay, O.; Hassali, M.; Fayaa, S.; Assiri, E.; Al Ghishiayan, K.; Alrasheedy, A.; Abbas, M. Impact of Ramadan Focused Education Program on medications adjustment for patients with type 2 diabetes in a primary health care institution in Saudi Arabia. Diabetes & Metabolic Syndrome: Clinical Research & Reviews. 2019;13(1):161-5.

      ]. Only 4 studies reported on FBG at two time-points [
      • El Toony L.F.
      • Hamad D.A.
      • Omar O.M.
      Outcome of focused pre-Ramadan education on metabolic and glycaemic parameters in patients with type 2 diabetes mellitus.
      ,
      • M'Guil M.
      • Ragala M.A.
      • El Guessabi L.
      • Fellat S.
      • Chraibi A.
      • Chabraoui L.
      • et al.
      Is Ramadan fasting safe in type 2 diabetic patients in view of the lack of significant effect of fasting on clinical and biochemical parameters, blood pressure, and glycemic control?.
      ,
      • Susilparat P.
      • Pattaraarchachai J.
      • Songchitsomboon S.
      • Ongroongruang S.
      Effectiveness of contextual education for self-management in Thai Muslims with type 2 diabetes mellitus during Ramadan.
      ,
      • Khatib F.A.
      • Shafagoj Y.A.
      Metabolic alterations as a result of Ramadan fasting in non-insulin-dependent diabetes mellitus patients in relation to food intake.
      ] and 1 study reported on it before Ramadan [
      • Ahmedani M.Y.
      • Alvi S.F.
      • Haque M.S.
      • Fawwad A.
      • Basit A.
      Implementation of Ramadan-specific diabetes management recommendations: a multi-centered prospective study from Pakistan.
      ]. Ten studies reported on weight at two time-points [
      • Bravis V.
      • Hui E.
      • Salih S.
      • Mehar S.
      • Hassanein M.
      • Devendra D.
      Ramadan education and awareness in diabetes (READ) programme for Muslims with type 2 diabetes who fast during Ramadan.
      ,
      • Ahmedani M.Y.
      • Alvi S.F.
      • Haque M.S.
      • Fawwad A.
      • Basit A.
      Implementation of Ramadan-specific diabetes management recommendations: a multi-centered prospective study from Pakistan.
      ,
      • Tourkmani A.M.
      • Hassali M.A.
      • Alharbi T.J.
      • Alkhashan H.I.
      • Alobikan A.H.
      • Bakhiet A.H.
      • et al.
      Impact of Ramadan focused education program on hypoglycemic risk and metabolic control for patients with type 2 diabetes.
      ,
      • Zainudin S.B.
      • Abu Bakar K.N.B.
      • Abdullah S.B.
      • Hussain A.B.
      Diabetes education and medication adjustment in Ramadan (DEAR) program prepares for self-management during fasting with tele-health support from pre-Ramadan to post-Ramadan.
      ,
      • El Toony L.F.
      • Hamad D.A.
      • Omar O.M.
      Outcome of focused pre-Ramadan education on metabolic and glycaemic parameters in patients with type 2 diabetes mellitus.
      ,
      • Hassanein M.
      • Abdelgadir E.
      • Bashier A.
      • Rashid F.
      • Saeed M.A.
      • Khalifa A.
      • et al.
      The role of optimum diabetes care in form of Ramadan focused diabetes education, flash glucose monitoring system and pre-Ramadan dose adjustments in the safety of Ramadan fasting in high risk patients with diabetes.
      ,

      Jamoussi HBO, R.; Chaabouni, S.; Gamoudi, A.; Berriche, O.; Mahjoub, F.; Sebai, Amrouche, C. . Interest of the therapeutic education in patients with type 2 diabetes observing the fast of Ramadan. AJM. 2017;53(1):71-5.

      ,
      • M'Guil M.
      • Ragala M.A.
      • El Guessabi L.
      • Fellat S.
      • Chraibi A.
      • Chabraoui L.
      • et al.
      Is Ramadan fasting safe in type 2 diabetic patients in view of the lack of significant effect of fasting on clinical and biochemical parameters, blood pressure, and glycemic control?.
      ,
      • Susilparat P.
      • Pattaraarchachai J.
      • Songchitsomboon S.
      • Ongroongruang S.
      Effectiveness of contextual education for self-management in Thai Muslims with type 2 diabetes mellitus during Ramadan.
      ,
      • Khatib F.A.
      • Shafagoj Y.A.
      Metabolic alterations as a result of Ramadan fasting in non-insulin-dependent diabetes mellitus patients in relation to food intake.
      ] and 2 studies reported on weight at baseline only [

      Tourkmani AA, T. ; Bin Rsheed, A.; AlRasheed, A.; AlBattal, S.; Abdelhay, O.; Hassali, M.; Fayaa, S.; Assiri, E.; Al Ghishiayan, K.; Alrasheedy, A.; Abbas, M. Impact of Ramadan Focused Education Program on medications adjustment for patients with type 2 diabetes in a primary health care institution in Saudi Arabia. Diabetes & Metabolic Syndrome: Clinical Research & Reviews. 2019;13(1):161-5.

      ,
      • Eid Y.M.
      • Sahmoud S.I.
      • Abdelsalam M.M.
      • Eichorst B.
      Empowerment-based diabetes self-management education to maintain glycemic targets during ramadan fasting in people with diabetes who are on conventional insulin: a feasibility study.
      ]. Eight studies reported on the change in BMI at two time points [
      • McEwen L.N.
      • Ibrahim M.
      • Ali N.M.
      • Assaad-Khalil S.H.
      • Tantawi H.R.
      • Nasr G.
      • et al.
      Impact of an individualized type 2 diabetes education program on clinical outcomes during Ramadan.
      ,
      • Ahmedani M.Y.
      • Alvi S.F.
      • Haque M.S.
      • Fawwad A.
      • Basit A.
      Implementation of Ramadan-specific diabetes management recommendations: a multi-centered prospective study from Pakistan.
      ,
      • Tourkmani A.M.
      • Hassali M.A.
      • Alharbi T.J.
      • Alkhashan H.I.
      • Alobikan A.H.
      • Bakhiet A.H.
      • et al.
      Impact of Ramadan focused education program on hypoglycemic risk and metabolic control for patients with type 2 diabetes.
      ,
      • Zainudin S.B.
      • Abu Bakar K.N.B.
      • Abdullah S.B.
      • Hussain A.B.
      Diabetes education and medication adjustment in Ramadan (DEAR) program prepares for self-management during fasting with tele-health support from pre-Ramadan to post-Ramadan.
      ,
      • El Toony L.F.
      • Hamad D.A.
      • Omar O.M.
      Outcome of focused pre-Ramadan education on metabolic and glycaemic parameters in patients with type 2 diabetes mellitus.
      ,

      Jamoussi HBO, R.; Chaabouni, S.; Gamoudi, A.; Berriche, O.; Mahjoub, F.; Sebai, Amrouche, C. . Interest of the therapeutic education in patients with type 2 diabetes observing the fast of Ramadan. AJM. 2017;53(1):71-5.

      ,
      • M'Guil M.
      • Ragala M.A.
      • El Guessabi L.
      • Fellat S.
      • Chraibi A.
      • Chabraoui L.
      • et al.
      Is Ramadan fasting safe in type 2 diabetic patients in view of the lack of significant effect of fasting on clinical and biochemical parameters, blood pressure, and glycemic control?.
      ,
      • Susilparat P.
      • Pattaraarchachai J.
      • Songchitsomboon S.
      • Ongroongruang S.
      Effectiveness of contextual education for self-management in Thai Muslims with type 2 diabetes mellitus during Ramadan.
      ], while 2 other studies reported on it before Ramadan [

      Tourkmani AA, T. ; Bin Rsheed, A.; AlRasheed, A.; AlBattal, S.; Abdelhay, O.; Hassali, M.; Fayaa, S.; Assiri, E.; Al Ghishiayan, K.; Alrasheedy, A.; Abbas, M. Impact of Ramadan Focused Education Program on medications adjustment for patients with type 2 diabetes in a primary health care institution in Saudi Arabia. Diabetes & Metabolic Syndrome: Clinical Research & Reviews. 2019;13(1):161-5.

      ,
      • Ahmedani M.Y.
      • Haque M.S.
      • Basit A.
      • Fawwad A.
      • Alvi S.F.
      Ramadan prospective diabetes study: the role of drug dosage and timing alteration, active glucose monitoring and patient education.
      ]. Only 2 studies reported on waist circumference at two time-points [
      • Ahmedani M.Y.
      • Alvi S.F.
      • Haque M.S.
      • Fawwad A.
      • Basit A.
      Implementation of Ramadan-specific diabetes management recommendations: a multi-centered prospective study from Pakistan.
      ,
      • El Toony L.F.
      • Hamad D.A.
      • Omar O.M.
      Outcome of focused pre-Ramadan education on metabolic and glycaemic parameters in patients with type 2 diabetes mellitus.
      ]. Six studies reported on total cholesterol at two time-points [
      • Tourkmani A.M.
      • Hassali M.A.
      • Alharbi T.J.
      • Alkhashan H.I.
      • Alobikan A.H.
      • Bakhiet A.H.
      • et al.
      Impact of Ramadan focused education program on hypoglycemic risk and metabolic control for patients with type 2 diabetes.
      ,
      • El Toony L.F.
      • Hamad D.A.
      • Omar O.M.
      Outcome of focused pre-Ramadan education on metabolic and glycaemic parameters in patients with type 2 diabetes mellitus.
      ,
      • Hassanein M.
      • Abdelgadir E.
      • Bashier A.
      • Rashid F.
      • Saeed M.A.
      • Khalifa A.
      • et al.
      The role of optimum diabetes care in form of Ramadan focused diabetes education, flash glucose monitoring system and pre-Ramadan dose adjustments in the safety of Ramadan fasting in high risk patients with diabetes.
      ,

      Jamoussi HBO, R.; Chaabouni, S.; Gamoudi, A.; Berriche, O.; Mahjoub, F.; Sebai, Amrouche, C. . Interest of the therapeutic education in patients with type 2 diabetes observing the fast of Ramadan. AJM. 2017;53(1):71-5.

      ,
      • M'Guil M.
      • Ragala M.A.
      • El Guessabi L.
      • Fellat S.
      • Chraibi A.
      • Chabraoui L.
      • et al.
      Is Ramadan fasting safe in type 2 diabetic patients in view of the lack of significant effect of fasting on clinical and biochemical parameters, blood pressure, and glycemic control?.
      ,
      • Khatib F.A.
      • Shafagoj Y.A.
      Metabolic alterations as a result of Ramadan fasting in non-insulin-dependent diabetes mellitus patients in relation to food intake.
      ] and 7 studies reported on LDL-C, HDL-C, and TG at two time-points [
      • Tourkmani A.M.
      • Hassali M.A.
      • Alharbi T.J.
      • Alkhashan H.I.
      • Alobikan A.H.
      • Bakhiet A.H.
      • et al.
      Impact of Ramadan focused education program on hypoglycemic risk and metabolic control for patients with type 2 diabetes.
      ,
      • Zainudin S.B.
      • Abu Bakar K.N.B.
      • Abdullah S.B.
      • Hussain A.B.
      Diabetes education and medication adjustment in Ramadan (DEAR) program prepares for self-management during fasting with tele-health support from pre-Ramadan to post-Ramadan.
      ,
      • El Toony L.F.
      • Hamad D.A.
      • Omar O.M.
      Outcome of focused pre-Ramadan education on metabolic and glycaemic parameters in patients with type 2 diabetes mellitus.
      ,
      • Hassanein M.
      • Abdelgadir E.
      • Bashier A.
      • Rashid F.
      • Saeed M.A.
      • Khalifa A.
      • et al.
      The role of optimum diabetes care in form of Ramadan focused diabetes education, flash glucose monitoring system and pre-Ramadan dose adjustments in the safety of Ramadan fasting in high risk patients with diabetes.
      ,

      Jamoussi HBO, R.; Chaabouni, S.; Gamoudi, A.; Berriche, O.; Mahjoub, F.; Sebai, Amrouche, C. . Interest of the therapeutic education in patients with type 2 diabetes observing the fast of Ramadan. AJM. 2017;53(1):71-5.

      ,
      • M'Guil M.
      • Ragala M.A.
      • El Guessabi L.
      • Fellat S.
      • Chraibi A.
      • Chabraoui L.
      • et al.
      Is Ramadan fasting safe in type 2 diabetic patients in view of the lack of significant effect of fasting on clinical and biochemical parameters, blood pressure, and glycemic control?.
      ,
      • Khatib F.A.
      • Shafagoj Y.A.
      Metabolic alterations as a result of Ramadan fasting in non-insulin-dependent diabetes mellitus patients in relation to food intake.
      ]. Four studies reported on the lipid profile before Ramadan [
      • Ahmedani M.Y.
      • Alvi S.F.
      • Haque M.S.
      • Fawwad A.
      • Basit A.
      Implementation of Ramadan-specific diabetes management recommendations: a multi-centered prospective study from Pakistan.
      ,
      • Susilparat P.
      • Pattaraarchachai J.
      • Songchitsomboon S.
      • Ongroongruang S.
      Effectiveness of contextual education for self-management in Thai Muslims with type 2 diabetes mellitus during Ramadan.
      ,

      Tourkmani AA, T. ; Bin Rsheed, A.; AlRasheed, A.; AlBattal, S.; Abdelhay, O.; Hassali, M.; Fayaa, S.; Assiri, E.; Al Ghishiayan, K.; Alrasheedy, A.; Abbas, M. Impact of Ramadan Focused Education Program on medications adjustment for patients with type 2 diabetes in a primary health care institution in Saudi Arabia. Diabetes & Metabolic Syndrome: Clinical Research & Reviews. 2019;13(1):161-5.

      ,
      • Ahmedani M.Y.
      • Haque M.S.
      • Basit A.
      • Fawwad A.
      • Alvi S.F.
      Ramadan prospective diabetes study: the role of drug dosage and timing alteration, active glucose monitoring and patient education.
      ]. Six studies reported on SBP and DBP at two time-points [
      • Ahmedani M.Y.
      • Alvi S.F.
      • Haque M.S.
      • Fawwad A.
      • Basit A.
      Implementation of Ramadan-specific diabetes management recommendations: a multi-centered prospective study from Pakistan.
      ,
      • Tourkmani A.M.
      • Hassali M.A.
      • Alharbi T.J.
      • Alkhashan H.I.
      • Alobikan A.H.
      • Bakhiet A.H.
      • et al.
      Impact of Ramadan focused education program on hypoglycemic risk and metabolic control for patients with type 2 diabetes.
      ,
      • El Toony L.F.
      • Hamad D.A.
      • Omar O.M.
      Outcome of focused pre-Ramadan education on metabolic and glycaemic parameters in patients with type 2 diabetes mellitus.
      ,
      • Hassanein M.
      • Abdelgadir E.
      • Bashier A.
      • Rashid F.
      • Saeed M.A.
      • Khalifa A.
      • et al.
      The role of optimum diabetes care in form of Ramadan focused diabetes education, flash glucose monitoring system and pre-Ramadan dose adjustments in the safety of Ramadan fasting in high risk patients with diabetes.
      ,
      • M'Guil M.
      • Ragala M.A.
      • El Guessabi L.
      • Fellat S.
      • Chraibi A.
      • Chabraoui L.
      • et al.
      Is Ramadan fasting safe in type 2 diabetic patients in view of the lack of significant effect of fasting on clinical and biochemical parameters, blood pressure, and glycemic control?.
      ,
      • Susilparat P.
      • Pattaraarchachai J.
      • Songchitsomboon S.
      • Ongroongruang S.
      Effectiveness of contextual education for self-management in Thai Muslims with type 2 diabetes mellitus during Ramadan.
      ], while two other studies reported on blood pressure prior to Ramadan [

      Tourkmani AA, T. ; Bin Rsheed, A.; AlRasheed, A.; AlBattal, S.; Abdelhay, O.; Hassali, M.; Fayaa, S.; Assiri, E.; Al Ghishiayan, K.; Alrasheedy, A.; Abbas, M. Impact of Ramadan Focused Education Program on medications adjustment for patients with type 2 diabetes in a primary health care institution in Saudi Arabia. Diabetes & Metabolic Syndrome: Clinical Research & Reviews. 2019;13(1):161-5.

      ,
      • Ahmedani M.Y.
      • Haque M.S.
      • Basit A.
      • Fawwad A.
      • Alvi S.F.
      Ramadan prospective diabetes study: the role of drug dosage and timing alteration, active glucose monitoring and patient education.
      ]. Six studies reported on hypoglycemia at two time-points [
      • Bravis V.
      • Hui E.
      • Salih S.
      • Mehar S.
      • Hassanein M.
      • Devendra D.
      Ramadan education and awareness in diabetes (READ) programme for Muslims with type 2 diabetes who fast during Ramadan.
      ,
      • Zainudin S.B.
      • Abu Bakar K.N.B.
      • Abdullah S.B.
      • Hussain A.B.
      Diabetes education and medication adjustment in Ramadan (DEAR) program prepares for self-management during fasting with tele-health support from pre-Ramadan to post-Ramadan.
      ,
      • Hassanein M.
      • Abdelgadir E.
      • Bashier A.
      • Rashid F.
      • Saeed M.A.
      • Khalifa A.
      • et al.
      The role of optimum diabetes care in form of Ramadan focused diabetes education, flash glucose monitoring system and pre-Ramadan dose adjustments in the safety of Ramadan fasting in high risk patients with diabetes.
      ,

      Tourkmani AA, T. ; Bin Rsheed, A.; AlRasheed, A.; AlBattal, S.; Abdelhay, O.; Hassali, M.; Fayaa, S.; Assiri, E.; Al Ghishiayan, K.; Alrasheedy, A.; Abbas, M. Impact of Ramadan Focused Education Program on medications adjustment for patients with type 2 diabetes in a primary health care institution in Saudi Arabia. Diabetes & Metabolic Syndrome: Clinical Research & Reviews. 2019;13(1):161-5.

      ,
      • Ahmadani M.Y.
      • Riaz M.
      • Fawwad A.
      • Hydrie M.Z.
      • Hakeem R.
      • Basit A.
      Glycaemic trend during Ramadan in fasting diabetic subjects: a study from Pakistan.
      ,
      • Eid Y.M.
      • Sahmoud S.I.
      • Abdelsalam M.M.
      • Eichorst B.
      Empowerment-based diabetes self-management education to maintain glycemic targets during ramadan fasting in people with diabetes who are on conventional insulin: a feasibility study.
      ], however the methods of reporting were inconsistent across these studies. Zainudin et al. [
      • Zainudin S.B.
      • Abu Bakar K.N.B.
      • Abdullah S.B.
      • Hussain A.B.
      Diabetes education and medication adjustment in Ramadan (DEAR) program prepares for self-management during fasting with tele-health support from pre-Ramadan to post-Ramadan.
      ] and Bravis et al. [
      • Bravis V.
      • Hui E.
      • Salih S.
      • Mehar S.
      • Hassanein M.
      • Devendra D.
      Ramadan education and awareness in diabetes (READ) programme for Muslims with type 2 diabetes who fast during Ramadan.
      ] reported on hypoglycemia as the number of cases who had hypoglycemic events and Tourkmani et al reported on a hypoglycemic score pre and post Ramadan [

      Tourkmani AA, T. ; Bin Rsheed, A.; AlRasheed, A.; AlBattal, S.; Abdelhay, O.; Hassali, M.; Fayaa, S.; Assiri, E.; Al Ghishiayan, K.; Alrasheedy, A.; Abbas, M. Impact of Ramadan Focused Education Program on medications adjustment for patients with type 2 diabetes in a primary health care institution in Saudi Arabia. Diabetes & Metabolic Syndrome: Clinical Research & Reviews. 2019;13(1):161-5.

      ]. Hassanein et al and Eid et al reported on the average hypoglycemic episodes [
      • Hassanein M.
      • Abdelgadir E.
      • Bashier A.
      • Rashid F.
      • Saeed M.A.
      • Khalifa A.
      • et al.
      The role of optimum diabetes care in form of Ramadan focused diabetes education, flash glucose monitoring system and pre-Ramadan dose adjustments in the safety of Ramadan fasting in high risk patients with diabetes.
      ,
      • Eid Y.M.
      • Sahmoud S.I.
      • Abdelsalam M.M.
      • Eichorst B.
      Empowerment-based diabetes self-management education to maintain glycemic targets during ramadan fasting in people with diabetes who are on conventional insulin: a feasibility study.
      ] and Ahmedani et al reported on the number of minor and major hypoglycemic episodes pre and post Ramadan [
      • Ahmadani M.Y.
      • Riaz M.
      • Fawwad A.
      • Hydrie M.Z.
      • Hakeem R.
      • Basit A.
      Glycaemic trend during Ramadan in fasting diabetic subjects: a study from Pakistan.
      ]. Only one study reported on the incidence of DKA during Ramadan [
      • Hassanein M.
      • Abdelgadir E.
      • Bashier A.
      • Rashid F.
      • Saeed M.A.
      • Khalifa A.
      • et al.
      The role of optimum diabetes care in form of Ramadan focused diabetes education, flash glucose monitoring system and pre-Ramadan dose adjustments in the safety of Ramadan fasting in high risk patients with diabetes.
      ] and another study reported on the incidence of ischemic events pre-Ramadan [

      Jamoussi HBO, R.; Chaabouni, S.; Gamoudi, A.; Berriche, O.; Mahjoub, F.; Sebai, Amrouche, C. . Interest of the therapeutic education in patients with type 2 diabetes observing the fast of Ramadan. AJM. 2017;53(1):71-5.

      ]. Funnel plots were created to test for small-study effects.

      3.2 Synthesis of results

      • 1.
        HbA1c and FBG
      Data were available from 9 studies on HbA1c (%) with 2034 participants [
      • Bravis V.
      • Hui E.
      • Salih S.
      • Mehar S.
      • Hassanein M.
      • Devendra D.
      Ramadan education and awareness in diabetes (READ) programme for Muslims with type 2 diabetes who fast during Ramadan.
      ,
      • McEwen L.N.
      • Ibrahim M.
      • Ali N.M.
      • Assaad-Khalil S.H.
      • Tantawi H.R.
      • Nasr G.
      • et al.
      Impact of an individualized type 2 diabetes education program on clinical outcomes during Ramadan.
      ,
      • Tourkmani A.M.
      • Hassali M.A.
      • Alharbi T.J.
      • Alkhashan H.I.
      • Alobikan A.H.
      • Bakhiet A.H.
      • et al.
      Impact of Ramadan focused education program on hypoglycemic risk and metabolic control for patients with type 2 diabetes.
      ,
      • Zainudin S.B.
      • Abu Bakar K.N.B.
      • Abdullah S.B.
      • Hussain A.B.
      Diabetes education and medication adjustment in Ramadan (DEAR) program prepares for self-management during fasting with tele-health support from pre-Ramadan to post-Ramadan.
      ,
      • El Toony L.F.
      • Hamad D.A.
      • Omar O.M.
      Outcome of focused pre-Ramadan education on metabolic and glycaemic parameters in patients with type 2 diabetes mellitus.
      ,
      • Hassanein M.
      • Abdelgadir E.
      • Bashier A.
      • Rashid F.
      • Saeed M.A.
      • Khalifa A.
      • et al.
      The role of optimum diabetes care in form of Ramadan focused diabetes education, flash glucose monitoring system and pre-Ramadan dose adjustments in the safety of Ramadan fasting in high risk patients with diabetes.
      ,
      • Lum Z.K.
      • See Toh W.Y.
      • Lim S.M.
      • Rusli K.D.B.
      • Abdul Shakoor S.
      • Tsou K.Y.K.
      • et al.
      Development of a collaborative algorithm for the management of type 2 diabetes during ramadan: an anchor on empowerment.
      ,

      Jamoussi HBO, R.; Chaabouni, S.; Gamoudi, A.; Berriche, O.; Mahjoub, F.; Sebai, Amrouche, C. . Interest of the therapeutic education in patients with type 2 diabetes observing the fast of Ramadan. AJM. 2017;53(1):71-5.

      ,
      • Srulovici E.
      • Leventer-Roberts M.
      • Curtis B.
      • He X.
      • Hoshen M.
      • Rotem M.
      • et al.
      Effectiveness of managing diabetes during ramadan conversation map intervention: a difference-in-differences (self-comparison) design.
      ,
      • Khatib F.A.
      • Shafagoj Y.A.
      Metabolic alterations as a result of Ramadan fasting in non-insulin-dependent diabetes mellitus patients in relation to food intake.
      ]. Pre-Ramadan focused education was associated with a significant reduction in HbA1c (%) (SMD −0.46, 95% CI −0.65 to −0.27). Heterogeneity for the outcomes was I2 = 77%. Four studies reported on FBG (mmol/L) in 1272 participants who received pre-Ramadan education [
      • El Toony L.F.
      • Hamad D.A.
      • Omar O.M.
      Outcome of focused pre-Ramadan education on metabolic and glycaemic parameters in patients with type 2 diabetes mellitus.
      ,
      • Srulovici E.
      • Leventer-Roberts M.
      • Curtis B.
      • He X.
      • Hoshen M.
      • Rotem M.
      • et al.
      Effectiveness of managing diabetes during ramadan conversation map intervention: a difference-in-differences (self-comparison) design.
      ,
      • M'Guil M.
      • Ragala M.A.
      • El Guessabi L.
      • Fellat S.
      • Chraibi A.
      • Chabraoui L.
      • et al.
      Is Ramadan fasting safe in type 2 diabetic patients in view of the lack of significant effect of fasting on clinical and biochemical parameters, blood pressure, and glycemic control?.
      ,
      • Susilparat P.
      • Pattaraarchachai J.
      • Songchitsomboon S.
      • Ongroongruang S.
      Effectiveness of contextual education for self-management in Thai Muslims with type 2 diabetes mellitus during Ramadan.
      ]. There was no significant effect on FBG (SMD −0.28, 95% CI −1.30 to 0.75). Heterogeneity for the outcomes was I2 = 96% (Figs. 2a, 2b). Self-blood glucose monitoring pre (6.87 ± 2.21 mmol/L) and post (6.87 ± 1.44 mmol/L) Ramadan was recorded following an educational program for people with T1DM and T2DM [
      • Eid Y.M.
      • Sahmoud S.I.
      • Abdelsalam M.M.
      • Eichorst B.
      Empowerment-based diabetes self-management education to maintain glycemic targets during ramadan fasting in people with diabetes who are on conventional insulin: a feasibility study.
      ], but was not included in the meta-analysis as we were unable to classify SMBG as pre or postprandial, as per protocol.
      • 2.
        Weight and BMI
      Figure thumbnail gr2a
      Fig. 2aForest plot representing the effect of Pre-Ramadan education on HbA1c (%) before and after Ramadan.
      Figure thumbnail gr2b
      Fig. 2bForest Plot representing the effect of Pre-Ramadan education on FBG (mmol/L) before and after Ramadan.
      Nine studies reported on weight in 1109 participants [
      • Bravis V.
      • Hui E.
      • Salih S.
      • Mehar S.
      • Hassanein M.
      • Devendra D.
      Ramadan education and awareness in diabetes (READ) programme for Muslims with type 2 diabetes who fast during Ramadan.
      ,
      • Ahmedani M.Y.
      • Alvi S.F.
      • Haque M.S.
      • Fawwad A.
      • Basit A.
      Implementation of Ramadan-specific diabetes management recommendations: a multi-centered prospective study from Pakistan.
      ,
      • Tourkmani A.M.
      • Hassali M.A.
      • Alharbi T.J.
      • Alkhashan H.I.
      • Alobikan A.H.
      • Bakhiet A.H.
      • et al.
      Impact of Ramadan focused education program on hypoglycemic risk and metabolic control for patients with type 2 diabetes.
      ,
      • Zainudin S.B.
      • Abu Bakar K.N.B.
      • Abdullah S.B.
      • Hussain A.B.
      Diabetes education and medication adjustment in Ramadan (DEAR) program prepares for self-management during fasting with tele-health support from pre-Ramadan to post-Ramadan.
      ,
      • El Toony L.F.
      • Hamad D.A.
      • Omar O.M.
      Outcome of focused pre-Ramadan education on metabolic and glycaemic parameters in patients with type 2 diabetes mellitus.
      ,
      • Hassanein M.
      • Abdelgadir E.
      • Bashier A.
      • Rashid F.
      • Saeed M.A.
      • Khalifa A.
      • et al.
      The role of optimum diabetes care in form of Ramadan focused diabetes education, flash glucose monitoring system and pre-Ramadan dose adjustments in the safety of Ramadan fasting in high risk patients with diabetes.
      ,

      Jamoussi HBO, R.; Chaabouni, S.; Gamoudi, A.; Berriche, O.; Mahjoub, F.; Sebai, Amrouche, C. . Interest of the therapeutic education in patients with type 2 diabetes observing the fast of Ramadan. AJM. 2017;53(1):71-5.

      ,
      • M'Guil M.
      • Ragala M.A.
      • El Guessabi L.
      • Fellat S.
      • Chraibi A.
      • Chabraoui L.
      • et al.
      Is Ramadan fasting safe in type 2 diabetic patients in view of the lack of significant effect of fasting on clinical and biochemical parameters, blood pressure, and glycemic control?.
      ,
      • Susilparat P.
      • Pattaraarchachai J.
      • Songchitsomboon S.
      • Ongroongruang S.
      Effectiveness of contextual education for self-management in Thai Muslims with type 2 diabetes mellitus during Ramadan.
      ,
      • Khatib F.A.
      • Shafagoj Y.A.
      Metabolic alterations as a result of Ramadan fasting in non-insulin-dependent diabetes mellitus patients in relation to food intake.
      ] and demonstrated a significant increase in weight (SMD 0.44, 95% CI 0.06 to 0.81). The heterogeneity of the outcomes was I2 = 0%. Eight studies reported on BMI in 1398 participants [
      • McEwen L.N.
      • Ibrahim M.
      • Ali N.M.
      • Assaad-Khalil S.H.
      • Tantawi H.R.
      • Nasr G.
      • et al.
      Impact of an individualized type 2 diabetes education program on clinical outcomes during Ramadan.
      ,
      • Ahmedani M.Y.
      • Alvi S.F.
      • Haque M.S.
      • Fawwad A.
      • Basit A.
      Implementation of Ramadan-specific diabetes management recommendations: a multi-centered prospective study from Pakistan.
      ,
      • Tourkmani A.M.
      • Hassali M.A.
      • Alharbi T.J.
      • Alkhashan H.I.
      • Alobikan A.H.
      • Bakhiet A.H.
      • et al.
      Impact of Ramadan focused education program on hypoglycemic risk and metabolic control for patients with type 2 diabetes.
      ,
      • Zainudin S.B.
      • Abu Bakar K.N.B.
      • Abdullah S.B.
      • Hussain A.B.
      Diabetes education and medication adjustment in Ramadan (DEAR) program prepares for self-management during fasting with tele-health support from pre-Ramadan to post-Ramadan.
      ,
      • El Toony L.F.
      • Hamad D.A.
      • Omar O.M.
      Outcome of focused pre-Ramadan education on metabolic and glycaemic parameters in patients with type 2 diabetes mellitus.
      ,

      Jamoussi HBO, R.; Chaabouni, S.; Gamoudi, A.; Berriche, O.; Mahjoub, F.; Sebai, Amrouche, C. . Interest of the therapeutic education in patients with type 2 diabetes observing the fast of Ramadan. AJM. 2017;53(1):71-5.

      ,
      • M'Guil M.
      • Ragala M.A.
      • El Guessabi L.
      • Fellat S.
      • Chraibi A.
      • Chabraoui L.
      • et al.
      Is Ramadan fasting safe in type 2 diabetic patients in view of the lack of significant effect of fasting on clinical and biochemical parameters, blood pressure, and glycemic control?.
      ,
      • Susilparat P.
      • Pattaraarchachai J.
      • Songchitsomboon S.
      • Ongroongruang S.
      Effectiveness of contextual education for self-management in Thai Muslims with type 2 diabetes mellitus during Ramadan.
      ] and showed no significant effect (SMD −0.24, 95% CI −0.97 to 0.49). The heterogeneity for the outcomes was I2 = 82%. Two studies reported on WC in 508 participants [
      • Ahmedani M.Y.
      • Alvi S.F.
      • Haque M.S.
      • Fawwad A.
      • Basit A.
      Implementation of Ramadan-specific diabetes management recommendations: a multi-centered prospective study from Pakistan.
      ,
      • El Toony L.F.
      • Hamad D.A.
      • Omar O.M.
      Outcome of focused pre-Ramadan education on metabolic and glycaemic parameters in patients with type 2 diabetes mellitus.
      ] and showed no significant effect (SMD = 0.52, −1.20 to 2.23). The heterogeneity for the outcomes was I2 = 0% (Figs. 2c, 2d).
      • 3.
        Lipid profile
      Figure thumbnail gr2c
      Fig. 2cForest Plot representing the effect of Pre-Ramadan education on weight (Kg) before and after Ramadan.
      Figure thumbnail gr2d
      Fig. 2dForest Plot representing the effect of Pre-Ramadan education on BMI (Kg/m2) before and after Ramadan.
      Five studies reported on total cholesterol in 575 participants [
      • Tourkmani A.M.
      • Hassali M.A.
      • Alharbi T.J.
      • Alkhashan H.I.
      • Alobikan A.H.
      • Bakhiet A.H.
      • et al.
      Impact of Ramadan focused education program on hypoglycemic risk and metabolic control for patients with type 2 diabetes.
      ,
      • El Toony L.F.
      • Hamad D.A.
      • Omar O.M.
      Outcome of focused pre-Ramadan education on metabolic and glycaemic parameters in patients with type 2 diabetes mellitus.
      ,
      • Hassanein M.
      • Abdelgadir E.
      • Bashier A.
      • Rashid F.
      • Saeed M.A.
      • Khalifa A.
      • et al.
      The role of optimum diabetes care in form of Ramadan focused diabetes education, flash glucose monitoring system and pre-Ramadan dose adjustments in the safety of Ramadan fasting in high risk patients with diabetes.
      ,

      Jamoussi HBO, R.; Chaabouni, S.; Gamoudi, A.; Berriche, O.; Mahjoub, F.; Sebai, Amrouche, C. . Interest of the therapeutic education in patients with type 2 diabetes observing the fast of Ramadan. AJM. 2017;53(1):71-5.

      ,
      • M'Guil M.
      • Ragala M.A.
      • El Guessabi L.
      • Fellat S.
      • Chraibi A.
      • Chabraoui L.
      • et al.
      Is Ramadan fasting safe in type 2 diabetic patients in view of the lack of significant effect of fasting on clinical and biochemical parameters, blood pressure, and glycemic control?.
      ] and showed no significant effect on total cholesterol (SMD −0.06, 95% CI −0.22 to 0.10, I2 = 59%) (Fig. 2e). Seven studies reported on LDL in 1359 participants and TG in 1462 participants [
      • Tourkmani A.M.
      • Hassali M.A.
      • Alharbi T.J.
      • Alkhashan H.I.
      • Alobikan A.H.
      • Bakhiet A.H.
      • et al.
      Impact of Ramadan focused education program on hypoglycemic risk and metabolic control for patients with type 2 diabetes.
      ,
      • Zainudin S.B.
      • Abu Bakar K.N.B.
      • Abdullah S.B.
      • Hussain A.B.
      Diabetes education and medication adjustment in Ramadan (DEAR) program prepares for self-management during fasting with tele-health support from pre-Ramadan to post-Ramadan.
      ,
      • El Toony L.F.
      • Hamad D.A.
      • Omar O.M.
      Outcome of focused pre-Ramadan education on metabolic and glycaemic parameters in patients with type 2 diabetes mellitus.
      ,
      • Hassanein M.
      • Abdelgadir E.
      • Bashier A.
      • Rashid F.
      • Saeed M.A.
      • Khalifa A.
      • et al.
      The role of optimum diabetes care in form of Ramadan focused diabetes education, flash glucose monitoring system and pre-Ramadan dose adjustments in the safety of Ramadan fasting in high risk patients with diabetes.
      ,

      Jamoussi HBO, R.; Chaabouni, S.; Gamoudi, A.; Berriche, O.; Mahjoub, F.; Sebai, Amrouche, C. . Interest of the therapeutic education in patients with type 2 diabetes observing the fast of Ramadan. AJM. 2017;53(1):71-5.

      ,
      • Srulovici E.
      • Leventer-Roberts M.
      • Curtis B.
      • He X.
      • Hoshen M.
      • Rotem M.
      • et al.
      Effectiveness of managing diabetes during ramadan conversation map intervention: a difference-in-differences (self-comparison) design.
      ,
      • M'Guil M.
      • Ragala M.A.
      • El Guessabi L.
      • Fellat S.
      • Chraibi A.
      • Chabraoui L.
      • et al.
      Is Ramadan fasting safe in type 2 diabetic patients in view of the lack of significant effect of fasting on clinical and biochemical parameters, blood pressure, and glycemic control?.
      ] and six studies on HDL in 602 participants [
      • Tourkmani A.M.
      • Hassali M.A.
      • Alharbi T.J.
      • Alkhashan H.I.
      • Alobikan A.H.
      • Bakhiet A.H.
      • et al.
      Impact of Ramadan focused education program on hypoglycemic risk and metabolic control for patients with type 2 diabetes.
      ,
      • Zainudin S.B.
      • Abu Bakar K.N.B.
      • Abdullah S.B.
      • Hussain A.B.
      Diabetes education and medication adjustment in Ramadan (DEAR) program prepares for self-management during fasting with tele-health support from pre-Ramadan to post-Ramadan.
      ,
      • El Toony L.F.
      • Hamad D.A.
      • Omar O.M.
      Outcome of focused pre-Ramadan education on metabolic and glycaemic parameters in patients with type 2 diabetes mellitus.
      ,
      • Hassanein M.
      • Abdelgadir E.
      • Bashier A.
      • Rashid F.
      • Saeed M.A.
      • Khalifa A.
      • et al.
      The role of optimum diabetes care in form of Ramadan focused diabetes education, flash glucose monitoring system and pre-Ramadan dose adjustments in the safety of Ramadan fasting in high risk patients with diabetes.
      ,

      Jamoussi HBO, R.; Chaabouni, S.; Gamoudi, A.; Berriche, O.; Mahjoub, F.; Sebai, Amrouche, C. . Interest of the therapeutic education in patients with type 2 diabetes observing the fast of Ramadan. AJM. 2017;53(1):71-5.

      ,
      • M'Guil M.
      • Ragala M.A.
      • El Guessabi L.
      • Fellat S.
      • Chraibi A.
      • Chabraoui L.
      • et al.
      Is Ramadan fasting safe in type 2 diabetic patients in view of the lack of significant effect of fasting on clinical and biochemical parameters, blood pressure, and glycemic control?.
      ] and showed a significant reduction in LDL (SMD = -0.09 mmol/L; P = 0.0002; I2 = 0%) (Fig. 2f) with no significant effect on HDL (SMD 0.03, 95% CI −0.02 to 0.08, I2 = 57%) (Fig. 2g), but an increase in TG (SMD = 0.07 mmol/L; P = 0.02; I2 = 271%) (Fig. 2h).
      • 4.
        Blood pressure
      Figure thumbnail gr2e
      Fig. 2eForest Plot representing the effect of Pre-Ramadan education on total cholesterol (mmol/L) before and after Ramadan.
      Figure thumbnail gr2f
      Fig. 2fForest Plot representing the effect of Pre-Ramadan education on LDL (mmol/L) before and after Ramadan.
      Figure thumbnail gr2g
      Fig. 2gForest Plot representing the effect of Pre-Ramadan education on HDL (mmol/L) before and after Ramadan.
      Figure thumbnail gr2h
      Fig. 2hForest Plot representing the effect of Pre-Ramadan education on TG (mmol/L) before and after Ramadan.
      Six studies reported on SBP and DBP in 999 participants [
      • Ahmedani M.Y.
      • Alvi S.F.
      • Haque M.S.
      • Fawwad A.
      • Basit A.
      Implementation of Ramadan-specific diabetes management recommendations: a multi-centered prospective study from Pakistan.
      ,
      • Tourkmani A.M.
      • Hassali M.A.
      • Alharbi T.J.
      • Alkhashan H.I.
      • Alobikan A.H.
      • Bakhiet A.H.
      • et al.
      Impact of Ramadan focused education program on hypoglycemic risk and metabolic control for patients with type 2 diabetes.
      ,
      • El Toony L.F.
      • Hamad D.A.
      • Omar O.M.
      Outcome of focused pre-Ramadan education on metabolic and glycaemic parameters in patients with type 2 diabetes mellitus.
      ,
      • Hassanein M.
      • Abdelgadir E.
      • Bashier A.
      • Rashid F.
      • Saeed M.A.
      • Khalifa A.
      • et al.
      The role of optimum diabetes care in form of Ramadan focused diabetes education, flash glucose monitoring system and pre-Ramadan dose adjustments in the safety of Ramadan fasting in high risk patients with diabetes.
      ,
      • M'Guil M.
      • Ragala M.A.
      • El Guessabi L.
      • Fellat S.
      • Chraibi A.
      • Chabraoui L.
      • et al.
      Is Ramadan fasting safe in type 2 diabetic patients in view of the lack of significant effect of fasting on clinical and biochemical parameters, blood pressure, and glycemic control?.
      ,
      • Susilparat P.
      • Pattaraarchachai J.
      • Songchitsomboon S.
      • Ongroongruang S.
      Effectiveness of contextual education for self-management in Thai Muslims with type 2 diabetes mellitus during Ramadan.
      ] and showed no significant effect on SBP (SMD −1.36, 95% CI −7.14 to 4.41) or DBP (SMD −0.67, 95% CI −1.90 to 0.57). The heterogeneity of the outcomes SBP was I2 = 96%, DBP I2 = 66% (Figs. 2I, 2J).
      • 5.
        Hypoglycemia
      Figure thumbnail gr2i
      Fig. 2iForest Plot representing the effect of Pre-Ramadan education on SBP (mmHg) before and after Ramadan.
      Figure thumbnail gr2j
      Fig. 2jForest Plot representing the effect of Pre-Ramadan education on DBP (mmHg) before and after Ramadan.
      Only two studies reported on the number of cases with hypoglycemia in 84 participants [
      • Bravis V.
      • Hui E.
      • Salih S.
      • Mehar S.
      • Hassanein M.
      • Devendra D.
      Ramadan education and awareness in diabetes (READ) programme for Muslims with type 2 diabetes who fast during Ramadan.
      ,
      • Zainudin S.B.
      • Abu Bakar K.N.B.
      • Abdullah S.B.
      • Hussain A.B.
      Diabetes education and medication adjustment in Ramadan (DEAR) program prepares for self-management during fasting with tele-health support from pre-Ramadan to post-Ramadan.
      ] and showed no significant effect (OR 0.58, 95% CI 0.22 to 1.48). The heterogeneity of the outcomes was I2 = 0% (Fig. 2K). A 3-month pre-Ramadan educational program in 10 patients with T1DM and 4 patients with T2DM reported a 3-fold reduction in hypoglycemic events/month before and during Ramadan [
      • Eid Y.M.
      • Sahmoud S.I.
      • Abdelsalam M.M.
      • Eichorst B.
      Empowerment-based diabetes self-management education to maintain glycemic targets during ramadan fasting in people with diabetes who are on conventional insulin: a feasibility study.
      ]. In contrast, Ahmedani et al showed that despite an alteration in drug dosage and increased blood glucose monitoring there was no difference in hypoglycemic episodes between those who did and did not receive pre-Ramadan education [
      • Ahmedani M.Y.
      • Ahsan S.
      • Haque M.S.U.
      Role of Ramadan specific diabetes education (RSDE); a prospective study.
      ]. These studies by Eid et al and Ahmedani et al were not included in the meta-analysis as the method of reporting outcomes was not in accordance to our protocol.
      • 6.
        Other adverse events
      Figure thumbnail gr2k
      Fig. 2kForest Plot representing the effect of Pre-Ramadan education on hypoglycemia before and after Ramadan.
      Eid et al recorded no worsening in glycemic control or DKA in patients who received pre-Ramadan education [
      • Eid Y.M.
      • Sahmoud S.I.
      • Abdelsalam M.M.
      • Eichorst B.
      Empowerment-based diabetes self-management education to maintain glycemic targets during ramadan fasting in people with diabetes who are on conventional insulin: a feasibility study.
      ] and Hassanein et al and Jamoussin et al recorded no DKA events during Ramadan fasting, following pre-Ramadan education [
      • Hassanein M.
      • Abdelgadir E.
      • Bashier A.
      • Rashid F.
      • Saeed M.A.
      • Khalifa A.
      • et al.
      The role of optimum diabetes care in form of Ramadan focused diabetes education, flash glucose monitoring system and pre-Ramadan dose adjustments in the safety of Ramadan fasting in high risk patients with diabetes.
      ,

      Jamoussi HBO, R.; Chaabouni, S.; Gamoudi, A.; Berriche, O.; Mahjoub, F.; Sebai, Amrouche, C. . Interest of the therapeutic education in patients with type 2 diabetes observing the fast of Ramadan. AJM. 2017;53(1):71-5.

      ]. No ischemic events were observed during Ramadan, regardless of education [

      Jamoussi HBO, R.; Chaabouni, S.; Gamoudi, A.; Berriche, O.; Mahjoub, F.; Sebai, Amrouche, C. . Interest of the therapeutic education in patients with type 2 diabetes observing the fast of Ramadan. AJM. 2017;53(1):71-5.

      ] and Srulovivi et al found no change in hospital admissions during Ramadan, regardless of education (P = 0.21) [
      • Srulovici E.
      • Leventer-Roberts M.
      • Curtis B.
      • He X.
      • Hoshen M.
      • Rotem M.
      • et al.
      Effectiveness of managing diabetes during ramadan conversation map intervention: a difference-in-differences (self-comparison) design.
      ].

      3.3 Risk of bias of the included studies

      In the Ramadan focused education studies Egger’s test resulted in a value of P > 0.05 for the lipid profile, weight, waist circumference and hypoglycemia, whilst for HbA1c (%), FBG (mmol/L), BMI (Kg/m2), SBP (mmHg) and DBP (mmHg) it was P < 0.05. Sensitivity analysis was undertaken to account for the small study effects using two methods as recommended by the Cochrane group [

      Higgins JPT GSe. Cochrane Handbook for Systematic Reviews of Interventions.: John Wiley & Sons Ltd, the trium, Southern Gate, Chichester, West Sussex PO19 8SQ, Englnd, Telephone (+44) 1243 779777; 2017.

      ]. Risk of bias assessment using the Cochrane Collaboration’s tool for two randomized controlled studies is shown in (Fig. 3) [
      • Lum Z.K.
      • See Toh W.Y.
      • Lim S.M.
      • Rusli K.D.B.
      • Abdul Shakoor S.
      • Tsou K.Y.K.
      • et al.
      Development of a collaborative algorithm for the management of type 2 diabetes during ramadan: an anchor on empowerment.
      ,
      • Susilparat P.
      • Pattaraarchachai J.
      • Songchitsomboon S.
      • Ongroongruang S.
      Effectiveness of contextual education for self-management in Thai Muslims with type 2 diabetes mellitus during Ramadan.
      ]. Four observational studies were found to have publication bias as per the Egger’s test score [
      • Zainudin S.B.
      • Abu Bakar K.N.B.
      • Abdullah S.B.
      • Hussain A.B.
      Diabetes education and medication adjustment in Ramadan (DEAR) program prepares for self-management during fasting with tele-health support from pre-Ramadan to post-Ramadan.
      ,

      Jamoussi HBO, R.; Chaabouni, S.; Gamoudi, A.; Berriche, O.; Mahjoub, F.; Sebai, Amrouche, C. . Interest of the therapeutic education in patients with type 2 diabetes observing the fast of Ramadan. AJM. 2017;53(1):71-5.

      ,
      • Susilparat P.
      • Pattaraarchachai J.
      • Songchitsomboon S.
      • Ongroongruang S.
      Effectiveness of contextual education for self-management in Thai Muslims with type 2 diabetes mellitus during Ramadan.
      ,
      • Khatib F.A.
      • Shafagoj Y.A.
      Metabolic alterations as a result of Ramadan fasting in non-insulin-dependent diabetes mellitus patients in relation to food intake.
      ].
      Risk of bias assessment using the ROBINS-I tool is shown in (Table 1). Sensitivity analysis was performed to account for the heterogeneity and any potential bias.
      Table 1Risk of bias assessment for non-randomized studies.

      3.4 Sensitivity analysis

      In the event of small study effects, sensitivity analysis was carried out to examine how the results of the meta-analysis change under different assumptions. Due to the inherent difficulty in adjusting for publication bias for the sake of adjustment for heterogeneity and small study effects, we used comparison of fixed and random effects models (10.4.4.1) and the trim and fill strategy (10.4.4.2) as per the Cochrane recommendations [

      Higgins JPT GSe. Cochrane Handbook for Systematic Reviews of Interventions.: John Wiley & Sons Ltd, the trium, Southern Gate, Chichester, West Sussex PO19 8SQ, Englnd, Telephone (+44) 1243 779777; 2017.

      ].

      3.5 Comparing fixed and random-effects estimates

      Random effects meta-analysis was used for all study variables in anticipation of heterogeneity due to differences in study design and population. However, for those variables that presented a significant publication bias (Egger’s test P < 0.05), we applied the fixed effects model to account for the presence of small study effects. Heterogeneity remained the same for HbA1c (%), FBG (mmol/L), BMI (Kg/m2), SBP (mmHg) and DBP (mmHg) for the Ramadan focused education studies. All studies were included when calculating the overall effect size for the meta-analysis.

      3.6 Trim and fill strategy

      When removing the small studies to correct for the funnel plot asymmetry arising from publication bias (Egger’s test P < 0.05), P-values for Egger’s test remained the same for HbA1c (%), FBG (mmol/L), BMI (Kg/m2), SBP and DBP for Ramadan focused education studies. All studies were included to calculate the overall effect size for the meta-analysis

      4. Discussion

      Fasting during Ramadan for patients with diabetes carries a risk of several acute complications including hyperglycemia and hypoglycemia [
      • Lee S.W.
      • Lee J.Y.
      • Tan C.S.
      • Wong C.P.
      Strategies to make ramadan fasting safer in type 2 diabetics: a systematic review and network meta-analysis of randomized controlled trials and observational studies.
      ]. As such, most current recommendations advocate that patients with diabetes who wish to fast during Ramadan need to discuss the risks versus benefits of fasting with their healthcare providers [
      • Al-Arouj M.
      • Bouguerra R.
      • Buse J.
      • Hafez S.
      • Hassanein M.
      • Ibrahim M.A.
      • et al.
      Recommendations for management of diabetes during Ramadan.
      ,
      • International Diabetes
      Federation Guideline Development G. Global guideline for type 2 diabetes.
      ]. Ramadan focused education has been endorsed to empower patients with diabetes who fast to improve glycemic control and reduce hypoglycemia [
      • McEwen L.N.
      • Ibrahim M.
      • Ali N.M.
      • Assaad-Khalil S.H.
      • Tantawi H.R.
      • Nasr G.
      • et al.
      Impact of an individualized type 2 diabetes education program on clinical outcomes during Ramadan.
      ]. Our analysis together with a previous meta-analysis on educational and behavioral interventions in type 2 diabetes [
      • Gary T.L.
      • Genkinger J.M.
      • Guallar E.
      • Peyrot M.
      • Brancati F.L.
      Meta-analysis of randomized educational and behavioral interventions in type 2 diabetes.
      ] and a systematic review on self-management training in type 2 diabetes [
      • Norris S.L.
      • Engelgau M.M.
      • Narayan K.M.
      Effectiveness of self-management training in type 2 diabetes: a systematic review of randomized controlled trials.
      ] suggest that Ramadan focused education can reduce HbA1c in patients with type 2 diabetes who fast during Ramadan. In the present analysis whilst Ramadan education significantly reduced HbA1c, heterogeneity was high. FBG did not change with Ramadan focused education, possibly due to non-adherence to Ramadan education or skipping medication.
      A previous meta-analysis showed that Ramadan-focused education was associated with a reduction in hypoglycemia in observational studies (OR = 0.25) but not in RCTs (OR = 1) [
      • Lee S.W.
      • Lee J.Y.
      • Tan C.S.
      • Wong C.P.
      Strategies to make ramadan fasting safer in type 2 diabetics: a systematic review and network meta-analysis of randomized controlled trials and observational studies.
      ]. Hypoglycemia rates are lower in patients with type 2 diabetes when compared with type 1 diabetes, and in patients with type 2 diabetes on insulin compared to oral agents [
      • Ahmad J.
      • Pathan M.F.
      • Jaleel M.A.
      • Fathima F.N.
      • Raza S.A.
      • Khan A.K.
      • et al.
      Diabetic emergencies including hypoglycemia during Ramadan.
      ]. A recent study of 290 patients with type 1 and type 2 diabetes showed that hypoglycemia was more prevalent in those with type 1 diabetes and micro and macrovascular complications and in patients taking sulphonylureas and insulin [
      • Beshyah S.A.
      • Hassanein M.
      • Ahmedani M.Y.
      • Shaikh S.
      • Ba-Essa E.M.
      • Megallaa M.H.
      • et al.
      Diabetic hypoglycaemia during Ramadan fasting: A trans-national observational real-world study.
      ]. In the present analysis of the pooled effect of two studies with 84 patients with type 2 diabetes [
      • Bravis V.
      • Hui E.
      • Salih S.
      • Mehar S.
      • Hassanein M.
      • Devendra D.
      Ramadan education and awareness in diabetes (READ) programme for Muslims with type 2 diabetes who fast during Ramadan.
      ,
      • Zainudin S.B.
      • Abu Bakar K.N.B.
      • Abdullah S.B.
      • Hussain A.B.
      Diabetes education and medication adjustment in Ramadan (DEAR) program prepares for self-management during fasting with tele-health support from pre-Ramadan to post-Ramadan.
      ], there was no significant effect of Ramadan specific education, on the rates of hypoglycemia during fasting. Eid et al found a minor non-significant reduction in hypoglycemic events [
      • Eid Y.M.
      • Sahmoud S.I.
      • Abdelsalam M.M.
      • Eichorst B.
      Empowerment-based diabetes self-management education to maintain glycemic targets during ramadan fasting in people with diabetes who are on conventional insulin: a feasibility study.
      ], however, the total daily insulin dose was also lower during Ramadan.
      We show that Ramadan focused education was associated with weight gain [
      • Fernando H.A.
      • Zibellini J.
      • Harris R.A.
      • Seimon R.V.
      • Sainsbury A.
      Effect of Ramadan fasting on weight and body composition in healthy non-athlete adults.
      ]. Although heterogeneity was high, weight increased significantly with pre-Ramadan education and could be related to the emphasis on diet and exercise plans and adherence to not skipping meals and medication. Several previous studies have shown either no change in lipids or weight [
      • Sarraf-Zadegan N.
      • Atashi M.
      • Naderi G.A.
      • Baghai A.M.
      • Asgary S.
      • Fatehifar M.R.
      • et al.
      The effect of fasting in Ramadan on the values and interrelations between biochemical, coagulation and hematological factors.
      ] or a reduction in LDL [
      • Qujeq D.
      • Bijani K.
      • Kalavi K.
      • Mohiti J.
      • Aliakbarpour H.
      Effects of Ramadan fasting on serum low-density and high-density lipoprotein-cholesterol concentrations.
      ] and triglycerides [

      Pirsaheb SP, Y.; Navabi, S.J.; Rezaei, M.; Darbandi, M.; Niazi, P. . Fasting Consequences during Ramadan on Lipid Profile and Dietary Patterns. . J Fasting Health 2013;1((1)):6‐12.

      ] and an increase in HDL [
      • Shehab A.
      • Abdulle A.
      • El Issa A.
      • Al Suwaidi J.
      • Nagelkerke N.
      Favorable changes in lipid profile: the effects of fasting after Ramadan.
      ,
      • Maislos M.
      • Khamaysi N.
      • Assali A.
      • Abou-Rabiah Y.
      • Zvili I.
      • Shany S.
      Marked increase in plasma high-density-lipoprotein cholesterol after prolonged fasting during Ramadan.
      ] in subjects who fast during Ramadan. Our analysis shows no change in TC and HDL-C, a significant decrease in LDL, but a significant increase in TG following pre-Ramadan education. The increase in TG could be explained by the increase in weight and intake of high caloric food during Ramadan. Blood pressure was not affected by pre-Ramadan education [
      • Shadman Z.
      • Poorsoltan N.
      • Akhoundan M.
      • Larijani B.
      • Soleymanzadeh M.
      • Akhgar Zhand C.
      • et al.
      Ramadan major dietary patterns.
      ], although the meta-analysis only included 3 studies which may be insufficient to detect a positive effect. Previous studies have shown a reduction [
      • Susilparat P.
      • Pattaraarchachai J.
      • Songchitsomboon S.
      • Ongroongruang S.
      Effectiveness of contextual education for self-management in Thai Muslims with type 2 diabetes mellitus during Ramadan.
      ,
      • Shehab A.
      • Abdulle A.
      • El Issa A.
      • Al Suwaidi J.
      • Nagelkerke N.
      Favorable changes in lipid profile: the effects of fasting after Ramadan.
      ] or no change [
      • Tourkmani A.M.
      • Hassali M.A.
      • Alharbi T.J.
      • Alkhashan H.I.
      • Alobikan A.H.
      • Bakhiet A.H.
      • et al.
      Impact of Ramadan focused education program on hypoglycemic risk and metabolic control for patients with type 2 diabetes.
      ,
      • Hassanein M.
      • Abdelgadir E.
      • Bashier A.
      • Rashid F.
      • Saeed M.A.
      • Khalifa A.
      • et al.
      The role of optimum diabetes care in form of Ramadan focused diabetes education, flash glucose monitoring system and pre-Ramadan dose adjustments in the safety of Ramadan fasting in high risk patients with diabetes.
      ,
      • M'Guil M.
      • Ragala M.A.
      • El Guessabi L.
      • Fellat S.
      • Chraibi A.
      • Chabraoui L.
      • et al.
      Is Ramadan fasting safe in type 2 diabetic patients in view of the lack of significant effect of fasting on clinical and biochemical parameters, blood pressure, and glycemic control?.
      ,
      • Saleh SAE S.A.
      • Cherian B.
      • Mourou M.
      Effects of Ramadan fasting on Waist Circumference, Blood Pressure, Lipid Profile, and Blood Sugar on a Sample of Healthy Kuwaiti Men and Women.
      ] in blood pressure during Ramadan.
      It is important to note that the Ramadan focused education programmes are variable in their duration and content and will therefore impact differently on the outcomes. Zainudin et al provided a diabetes educational session through a focus group by a religious leader, endocrinologist, diabetes specialist nurse and physiotherapist and included topics on religious perspective of fasting, diabetes-related complications of fasting, diet, exercise and an interactive hands-on session on glucose monitoring and sick day management [
      • Zainudin S.B.
      • Abu Bakar K.N.B.
      • Abdullah S.B.
      • Hussain A.B.
      Diabetes education and medication adjustment in Ramadan (DEAR) program prepares for self-management during fasting with tele-health support from pre-Ramadan to post-Ramadan.
      ]. Tourkmani et al provided an educational session via a clinical pharmacist, primary care physician and dietician in individual and group sessions lasting 40–60 min on the signs and symptoms of hyper and hypoglycemia, SMBG, management of acute complications and dose adjustment [
      • Tourkmani A.M.
      • Hassali M.A.
      • Alharbi T.J.
      • Alkhashan H.I.
      • Alobikan A.H.
      • Bakhiet A.H.
      • et al.
      Impact of Ramadan focused education program on hypoglycemic risk and metabolic control for patients with type 2 diabetes.
      ,

      Tourkmani AA, T. ; Bin Rsheed, A.; AlRasheed, A.; AlBattal, S.; Abdelhay, O.; Hassali, M.; Fayaa, S.; Assiri, E.; Al Ghishiayan, K.; Alrasheedy, A.; Abbas, M. Impact of Ramadan Focused Education Program on medications adjustment for patients with type 2 diabetes in a primary health care institution in Saudi Arabia. Diabetes & Metabolic Syndrome: Clinical Research & Reviews. 2019;13(1):161-5.

      ]. Lum et al, provided individualized patient education on SMBG timing, a dietary plan and hypoglycemia management (30]. Jamoussi et al, focused on a dietary plan, symptoms of hypo and hyperglycemia, medication adherence and SMBG [

      Jamoussi HBO, R.; Chaabouni, S.; Gamoudi, A.; Berriche, O.; Mahjoub, F.; Sebai, Amrouche, C. . Interest of the therapeutic education in patients with type 2 diabetes observing the fast of Ramadan. AJM. 2017;53(1):71-5.

      ]. Hassanein et al advised-on dose adjustment and use of the freestyle Libre sensor [
      • Hassanein M.
      • Abdelgadir E.
      • Bashier A.
      • Rashid F.
      • Saeed M.A.
      • Khalifa A.
      • et al.
      The role of optimum diabetes care in form of Ramadan focused diabetes education, flash glucose monitoring system and pre-Ramadan dose adjustments in the safety of Ramadan fasting in high risk patients with diabetes.
      ]. Eltoony et al provided individualized educational sessions of 20–30 min each that discussed a dietary plan, physical activity, SMBG, and medication adjustment [
      • El Toony L.F.
      • Hamad D.A.
      • Omar O.M.
      Outcome of focused pre-Ramadan education on metabolic and glycaemic parameters in patients with type 2 diabetes mellitus.
      ]. McEwen et al, provided individualized education related to meal planning, physical activity, SMBG, and recognition and management of hypoglycemia and hyperglycemia [
      • McEwen L.N.
      • Ibrahim M.
      • Ali N.M.
      • Assaad-Khalil S.H.
      • Tantawi H.R.
      • Nasr G.
      • et al.
      Impact of an individualized type 2 diabetes education program on clinical outcomes during Ramadan.
      ] ]. M′guil et al, provided patient dietary and physical activity education and advise on dose adjustment [
      • M'Guil M.
      • Ragala M.A.
      • El Guessabi L.
      • Fellat S.
      • Chraibi A.
      • Chabraoui L.
      • et al.
      Is Ramadan fasting safe in type 2 diabetic patients in view of the lack of significant effect of fasting on clinical and biochemical parameters, blood pressure, and glycemic control?.
      ]. Susilparat et al, provided educational sessions on the complications of fasting, dietary planning and medication adjustment [
      • Susilparat P.
      • Pattaraarchachai J.
      • Songchitsomboon S.
      • Ongroongruang S.
      Effectiveness of contextual education for self-management in Thai Muslims with type 2 diabetes mellitus during Ramadan.
      ]. Bravis et al, provided educational sessions according to National Institute for Health and Clinical Excellence (NICE) including education on meal planning, physical activity, glucose monitoring, hypoglycemia, dosage and timing of medications [
      • Bravis V.
      • Hui E.
      • Salih S.
      • Mehar S.
      • Hassanein M.
      • Devendra D.
      Ramadan education and awareness in diabetes (READ) programme for Muslims with type 2 diabetes who fast during Ramadan.
      ]. Ahmedani et al, provided an individualized educational session (15–20 min) on the recognition and management of hypo and hyperglycemia and SMBG assessment [
      • Ahmedani M.Y.
      • Alvi S.F.
      • Haque M.S.
      • Fawwad A.
      • Basit A.
      Implementation of Ramadan-specific diabetes management recommendations: a multi-centered prospective study from Pakistan.
      ]. In another study by Ahmedani et al, all patients received written educational material and on a one-to-one or group session on SMBG, exercise and meal planning, dose adjustment and management of hypoglycemia [
      • Ahmedani M.Y.
      • Ahsan S.
      • Haque M.S.U.
      Role of Ramadan specific diabetes education (RSDE); a prospective study.
      ]. Srulovici et al discussed the risks of fasting during Ramadan, pathophysiological changes during fasting, exercise, meal planning and medication management [
      • Srulovici E.
      • Leventer-Roberts M.
      • Curtis B.
      • He X.
      • Hoshen M.
      • Rotem M.
      • et al.
      Effectiveness of managing diabetes during ramadan conversation map intervention: a difference-in-differences (self-comparison) design.
      ]. Eid et al provided intense diabetes self-management education (DSME) over 3 h with reinforcement, 3 months before Ramadan and discussed nutrition, meal planning and carbohydrate counting in addition to strategies to prevent and treat hypoglycemia [
      • Eid Y.M.
      • Sahmoud S.I.
      • Abdelsalam M.M.
      • Eichorst B.
      Empowerment-based diabetes self-management education to maintain glycemic targets during ramadan fasting in people with diabetes who are on conventional insulin: a feasibility study.
      ].

      4.1 Strengths and limitations of the current study

      To our knowledge, this is the first comprehensive systematic review and meta-analyses addressing the effect of Ramadan specific education on a range of metabolic and anthropometric measures in patients with diabetes who fast during Ramadan. Our study considers the effect of diabetes education in different populations from a range of countries. We have identified a lack of randomized head to head studies comparing Ramadan specific education with no education and therefore compared the results from studies with and without education to provide the most comprehensive summary of evidence available to date. The limitations of this analysis include the inclusion of studies of people with type 2 diabetes only and not those with type 1 diabetes and gestational diabetes. There was considerable heterogeneity in the design of observational studies as well as the definition and reporting of results. In addition, many trials were not powered to assess our predefined outcomes, and as such increases the risk of reporting bias. More studies are needed before guidelines can endorse structured pre-Ramadan education to manage diabetes during Ramadan.

      5. Conclusion

      It is important that recommendations are evidence based and deficiencies in the current evidence base are identified and addressed. This comprehensive systematic review and meta-analysis demonstrates that Ramadan specific education confers benefits in relation to a reduction in HbA1c and LDL, but increases weight and TG, whilst having no effect on TC, HDL, blood pressure or hypoglycemia.

      6. Contributions

      R.A.M. and H.G. formulated the research question and defined the search terms. P.M. carried out the electronic searches. H.G., H.A., and H.P. carried out the screening and data extraction. H.G. carried out the meta-analysis. R.A.M. and H.G. wrote the manuscript and all authors were involved in reviewing the final manuscript. R.A.M. approved the final version of the manuscript.

      Funding

      No funding was received by the authors.

      Declaration of Competing Interest

      No potential conflicts of interest relevant to this article.

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