Fasting during Ramadan: A Comprehensive Review for Primary Care Providers
Round 1
Reviewer 1 Report
This article discusses issues faced by people with diabetes who participate in Ramadan. Indeed, prolonged fasting over periods of 10 to 18 hours carries risks for people whose chronic illness can be exacerbated by fasting. This review aims to highlight the important points to be monitored during the care of diabetic patients who practice Ramadan, particularly in terms of treatment and blood sugar monitoring.
If this article presents a relevant objective, the disorganization of the plan of the article, the lack of scientific references and the absence of nuance on the beneficial effects of Ramadan make reading difficult, and can question the objectivity of the authors.
It therefore seems essential to rewrite the article in order to qualify the remarks, and to provide much more scientific evidence to describe the physiology of the young person, the risk for diabetic patients, and the solutions provided for better follow-up of these patients.
Major points:
- In the abstract, concerning the objective of this study, it should be to help practitioners to better guide patients, i.e. to give them scientific arguments to better enable it, rather than to advise patients directly, since these are not the readers of this journal. This article could also give indications to scientists on what remains to be done to better understand the effects of Ramadan (positive and negative) in patients with diabetes.
- The purpose of the review is not clearly expressed and should appear in the introduction
- The advice given in the different chapters should better refer to published studies. indeed, this review looks more like advice given to patients than a summary of the results of articles dealing with the issue of whether or not to do Ramadan for diabetic subjects and what are the consequences, positive and/or negative depending on different possible conditions.
The guidelines are clearly done on the official site: www.idf.org/guidelines/diabetes-in-ramadan, then this review must focus on articles that answer the scientific question that is not clearly given.
- Not enough references support the article (only 31 for a 12-page article), many studies on diabetes and Ramadan are absent, the bibliography is too light for a review.
- The take home message is not enough scientific, based upon articles.
- The conclusion and the outlook need to be improved.
Minor points:
Ligne 96: Per exemple: “Individuals with type 2 diabetes can safely fortify their suhoor and Iftar meals with dates within serving guidelines.” The authors must remain cautious concerning the beneficial and safety effects of dates and in particular when these are associated with the intake of other foods rich in sucrose and various and varied fats.
- Are there different effects between Ramadans that last rather 10 hours compared to a Ramadan of 18 hours of fasting with regard to metabolic parameters?
Ligne 112: the title should be: 5. Metabolic effects of Ramadan fasting
Ligne 136: The EPIDIAR study discovered …
Ligne 179: Whar is the scientific reference(s) for the 15/15 rule? Where the authors can find this official recommendations?
- Part of 4. Physiology of the fast is too succinct and disorganized. Mention of Ramadan as a time-restricted feeding but no detail on it.
- Mention of the beneficial effects of Ramadan but no mention of the absence of effect or negative effects on weight and blood sugar (eg: https://www.ncbi.nlm.nih.gov/pmc/articles/ PMC6775544/; https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5713716/) while they exist and it seems crucial to mention them, especially for an article that wants to warn of the risks of Ramadan for diabetics. The article clearly lacks objectivity on Ramadan, its effects should be qualified.
- Specification of the consumption of dishes rich in carbohydrates/fats (line 77 to 80) but no mention of the effect of this type of diet for diabetes or circadian rhythms, although it is well known that the consumption of carbohydrates/sugars in the evening decreases glucose tolerance, which is critical for diabetics (references: Morris, CJ; Yang, JN; Garcia, JI; Myers, S.; Bozzi, I.; Wang, W.; Buxton, OM; Shea, SA; Scheer, FAJL Endogenous Circadian System and Circadian Misalignment Impact Glucose Tolerance via Separate Mechanisms in Humans. Proc. Natl. Acad. Sci. USA 2015, 112, E2225-E2234.; Qian, J.; Scheer, FA Circadian System and Glucose Metabolism: Implications for Physiology and Disease Trends Endocrinol Metab TEM 2016, 27, 282-293; Van Cauter, E.; Polonsky, KS; Scheen, AJ Roles of Circadian Rhythmicity and Sleep in Human Glucose Regulation. Endocr Rev. 1997, 18, 716-738.)
- Diagrams would be welcome to illustrate the review. For example, a balance sheet that would include all the recommendations to take into account to help diabetics manage their diabetes safely while participating in Ramadan.
Author Response
Thank you for your comments. We have addressed each of the concerns in the attached response.
Author Response File: 
Author Response.docx
Reviewer 2 Report
Needs to make a brief review of authors younger years 2022 and 2021 , taking into account the importance of the subject at the moment of diabetes in the world
Author Response
Thank you for your review of our manuscript. We have completed a new literature review and have expanded and updated our references. Indeed this topic has received a lot of press since 2019.
Thanks again!
Round 2
Reviewer 1 Report
The article has been reviewed in depth and has clearly been improved by taking into account all of our suggestions.
it is still necessary to reread the article and correct the errors concerning the spelling and the grammar. The article must be proofread by an English speaker.
