Download Diabetes care and Ramadan: to fast or not to fast?

TRANS-CULTURAL MEDICINE
Diabetes care and Ramadan:
to fast or not to fast?
SAKERA SHAIKH, DIANE JAMES, JOHN MORRISSEY, VINOD PATEL
month of Ramadan the Quran was revealed.... Therefore whoever of you is present
“ Inin the
that month let him fast. But he who is ill or on a journey shall fast a similar number of
days later on. God desires your well-being not your discomfort.
” The Quran
Introduction
T
he devout Muslim will wish to follow the
instruction of Allah, revealed to Muhammed, to
fast from dawn to sunset for the whole month of
Ramadan. This practice may place Muslim patients with
diabetes at risk. Diabetes affects over 20% of the
Muslim population in Britain, five times its prevalence
in the white Caucasian population.1
With advice, support and careful attention to
glycaemic control most patients can fast safely.
However, in the absence of such precautions patients
may be at hazard of hypoglycaemia or ketoacidosis. For
some patients fasting is dangerous and they should be
advised to seek exemption. This short article offers a
guide to the care of the Muslim patient with diabetes
during Ramadan.
Islam
Islam is not only a religion but an entire way of life. The core beliefs
of Islam are that there is only one God, Allah, that Muhammed was
a prophet sent by Allah to mankind, and that the Quran, the revelations by Allah to Muhammed, is the word of God.
The Arabic word Islam means submission and obedience.
Submission is acceptance of Allah's commands. Obedience
means putting Allah’s commands into practice.2 One who
accepts the Islamic way of life and acts accordingly is a Muslim.
There are approximately one billion Muslims in the world, about
1.6 million in the United Kingdom.3
The Islamic perception of healthcare has religious, cultural
and scientific dimensions. The relative importance given to each
Correspondence to: Mrs Sakera Shaikh
Diabetes and Endocrinology Centre, George Eliot Hospital NHS Trust,
College Street, Nuneaton, Warwickshire, CV10 7DJ, UK.
Tel: +44 (0)2476 351351; Fax: +44 (0)2476 865210
E-mail: [email protected]
Br J Diabetes Vasc Dis 2001;1:65–67
VOLUME 1 ISSUE 1 . AUGUST 2001
varies between cultures and according to the strength of an individual’s religious belief. It is believed that cure comes solely from
Allah and that doctors, teachers of religion and other such individuals are merely God’s instruments.3 The Muslim may seek
treatment by modern medicine but simultaneously approach the
learned teacher, aalim, for help and advice based on the Quran.
Fasting
Fasting is abstention from food and drink from dawn to sunset.
This also involves abstaining from intravenous fluid and intravenous, oral, aural and nasal medication. Fasting cultivates the
spirit of sacrifice and teaches self-discipline and sympathy for the
hungry and poor.4 A pre-dawn meal (suhr) is taken before the
start of the fasting day2-6 and a larger meal after sunset.
Fasting during Ramadan (sawm) is one of the five pillars of
Islam, the duties which form the basis of the Muslim way of
life.2,3 The others are shahadah, a declaration of faith, salah, five
compulsory daily prayers, zakat, alms for the poor and needy,
and hajj, pilgrimage to Mecca.
Ramadan is the ninth month of the Islamic year. Islam follows
the lunar calendar in which one year equals twelve lunar months,
354 days. Each day in the Islamic year falls eleven days earlier
each solar year. Ramadan therefore circulates through the seasons. When Ramadan falls during the winter months in Britain a
fast can last ten hours, in summer up to nineteen. In the year 2001
of the Christian calendar Ramadan commences in November.
Exemptions from fasting
Fasting is obligatory upon every responsible and healthy Muslim.
To miss a fast intentionally without valid reason is a sin, subject
to a penalty of fasting for two months or providing a meal for
sixty people.3,5 However, some individuals are exempt:
● Children under the age of puberty.
● Those with learning difficulties and unable to understand the
nature and purpose of the fast.
● The old and frail.
● The acutely unwell.
● Those with chronic illnesses for whom fasting may be
detrimental to health.
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TRANS-CULTURAL MEDICINE
●
Those travelling a distance greater than 50 miles in a single
journey.
● Menstruating, pregnant and nursing women.
The unwell are allowed to desist from fasting for any period
from a single day to the whole month depending on the nature
of their illness.3,6 Individuals with chronic illness may substitute for
fasting by providing food each day for one person (fidya).5
Patients with diabetes fall into this category but many prefer to
meet their religious obligations by fasting.
The hazards of fasting
Alteration of eating pattern without appropriate adjustment to
the dosage and timing of insulin and/or oral medications may
result in unacceptable deterioration in glycaemic control.7
Insulin or sulphonylurea-treated patients run the risk of hypoglycaemia and some type 1 diabetic patients may risk ketoacidosis. Prolonged fasting, such as when Ramadan occurs during
the summer months, may create greater potential hazards than
fasts of shorter duration during the winter.
However, with appropriate counselling and guidance many
diabetic patients can fast safely.7,8 Provided acute metabolic
emergencies are avoided, a thirty day fast is medically neither
especially harmful nor beneficial. Studies have shown no dramatic or consistent changes in body weight, glycaemic control,
blood pressure or serum lipids over such a fast.3,6,9
Those who should not fast
Some diabetic patients should be advised against fasting during Ramadan:5
● People with ‘brittle’ type 1 diabetes.
● Type 1 or type 2 diabetic patients with poor glycaemic
control.
● Individuals known to be non-compliant with diet or
medication.
● Those with serious concurrent disease, including unstable
angina or uncontrolled hypertension.
● Patients with a history of recurrent diabetic ketoacidosis.
● Pregnant women.
● Patients with intercurrent infections.
● Patients with renal impairment of any severity because of
the risk of dehydration and uraemia.
● Elderly patients with reduced alertness.
● Those who have previously experienced severe
deterioration in glycaemic control during Ramadan.
Precautions for those who fast
Patients must have reasonably good glycaemic control before
commencing the fast.8 Education should start early to ensure
optimal control and include advice on diet, home blood glucose
monitoring, medication and the management of hypo- and
hyperglycaemia. The importance of continued compliance with
dietary recommendations should be emphasised.6,9 Breaking the
fast after sunset is not an excuse for over eating.
Specific individual guidelines should be given to each patient
to ensure maximum safety. Patients need to monitor blood glu-
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The clinical pharmacist and diabetes nurse specialist
counselling a muslim couple on diabetic care
cose throughout Ramadan with adjustment of their medication
as needed. Monitoring should be performed before the predawn meal and before and a few hours after the sunset meal.6
Patients must be advised to break their fast if there is severe deterioration in glycaemic control. It may be necessary to prescribe a
glucose gel (such as Hypostop™ gel) and/or glucagon.
Ideally there should be careful follow-up during Ramadan.
However, patients are often reluctant to attend clinic since
appropriate advice may not be given, also appointments
may coincide with prayer times or times at which the fast is
broken. Follow-up by telephone may be a more practicable
alternative.
During Ramadan many patients may seek advice from community and religious leaders. It is therefore important to build
a close working relationship between these leaders and the
diabetes team to ensure that advice given by both is consistent
and appropriate.
Patients on oral medication
Patients taking metformin alone are at no risk of hypoglycaemia
and fasting poses little hazard. However, the pre-Ramadan doses
should be reversed, so the usual morning dose is taken with the
sunset meal and the evening dose with the pre-dawn meal. If a
dose is usually taken at lunchtime it too should be taken with the
sunset meal.3,6,7,9
Patients taking a sulphonylurea (alone or in combination with
metformin) should use a short-acting agent such as tolbutamide
or gliclazide. Non-sulphonylurea post-prandial glucose regulators
such as repaglinide or nateglinide are alternatives. Long-acting
agents such as chlorpropamide and glibenclamide are hazardous
and must be avoided.10
As with metformin, the pre-Ramadan morning and evening
doses of a sulphonylurea should be reversed during the fast. If the
patient usually takes a once-daily agent such as glipizide or
glimepiride with breakfast it should be taken with the sunset meal
instead.
THE BRITISH JOURNAL OF DIABETES AND VASCULAR DISEASE
TRANS-CULTURAL MEDICINE
Patients on insulin
Conclusions
Many patients normally use premixed insulin (Mixtard,
Humulin, Humalog Mix) and to avoid hypoglycaemia it may be
necessary to change this for the duration of the fast. Use of a
short-acting insulin before the pre-dawn and sunset meals with
an intermediate insulin (Insulatard, Humulin I) in the evening
secures good control and is considered safe.
There should be no need for a drastic reduction in the total
dose of insulin. Many patients are insulin resistant and will still
require large doses.
Many patients will prefer to eat as soon after sunset as possible,
so they need to be able to inject insulin and eat immediately. The
use of very quick-acting insulin analogues (Humalog, Novorapid) is
convenient and secures better post-prandial glucose control.
If patients remain on premixed insulin, the morning and
evening doses should be reversed. If the doses are normally the
same, the morning dose should be reduced by about 50% and
a correspondingly larger dose taken before the sunset meal.
Adjustment of doses according to the results of home blood
glucose monitoring is essential.
Patients using insulin pumps (continuous subcutaneous
insulin infusion, CSII) should adjust their infusion rates carefully
according to results of frequent home blood glucose monitoring.
Most will need to reduce their basal infusion rate whilst increasing the bolus doses to cover the pre-dawn and sunset meals.
Sawm is fundamental to the Islamic way of life and the majority
of diabetic Muslims will wish to fast for the full month of
Ramadan. Our job is to help them perform that duty by providing support and advice so they fast safely and without complications.
References
1. Bhopal R, Unwin N, White M et al. Heterogeneity of coronary heart disease risk factors in Indian, Pakistani, Bangladeshi and European origin
populations: cross sectional study. BMJ 1999;319:215-20.
2. Sarwar G. Islam – Belief & Teachings. Muslim Educational Trust.
3. Sheikh A, Gatrad AR. Caring for Muslim Patients. Radcliffe Medical Press.
2000.
4. Sheikh Abdul Rauf. Muslim Way of Life. Taj Company. New Delhi. 1984.
5. El-Geyoushi M. I. Teachings of Islam. Islamic Cultural Centre. London.
6. Freidoun A, Siahkolah B. Ramadan Fasting & Diabetes Mellitus. Int J
Ramadan Fasting Res 1998;2:8-17. (www. crescentlife.com).
7. Lakhdar A. The Fast of Ramadan and the Diabetic Patient. Practical
Diabetes International 1999;16:7.
8. Uysal A, Erdogan MF, Fahin G et al. Clinical and Metabolic Effects of
Fasting in 41 Type 2 diabetic patients during Ramadan. Diabetes Care
1998;21:2033-4.
9. Management of Diabetes Mellitus During the Holy Month of Ramadan:
Proceedings of an International Symposium. Cairo. Egypt. Practical
Diabetes International 1998;15(Suppl 1):S1-S23.
10. Belkhadir J, El Ghomari, Klöcker N et al. Muslims with non-insulin dependant diabetes fasting during Ramadan: treating with glibenclamide. BMJ
307:292-5.
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