27 Jun, 14 | by BMJ
Dr Noma Salman is a Senior Tutor for Diabetes Qualifications from BMJ and University of Leicester. She is a GP who practices in Canada, and before that the UAE.
Fasting the holy month of Ramadan is one of the five pillars in the religion of Islam. The adult Muslim is expected to observe this special month by fasting, praying and devoting additional time in service of God. When fasting, Muslims are expected to stop eating, drinking and smoking from dawn till sunset. Ramadan lasts for one lunar month and ends with 3 days feast where Muslims break their fast and enjoy a variety of different social activities and food invitations; sweets constitute a major part of it.
The Muslim population is increasing and expected to rise from the current 1.6 billion to 2.2 billion by the year 2030. Adults and adolescents above the age of 14 are expected to observe Ramadan. They constitute approximately 1.2 billion (1), of which 77 million are estimated to have diabetes (2). Only healthy people are asked to fast. The sick, travelers, debilitated elderly people, and pregnant and lactating women, are exempt from this obligation. Despite this, many persons with diabetes insist on fasting which is sometimes against medical advice.
What is the effect of fasting on the glycemic control of people with diabetes? Who can fast? What are the contraindications of fasting? What kind of medical adjustments must be done before, during and after Ramadan? And how effective is patient education in achieving safe fasting and afterward feasting?
The main concerns and adverse effects of fasting are: Dehydration, Hypo and hyperglycemia attacks, Thrombosis and ketoacidosis.
Health care providers usually categorize patients into main 4 groups (3):
• Low risk group: where patients are well-controlled and treated with diet alone or diet and metformin;
• Moderate risk: Well-controlled patients treated with short-acting insulin secretagogues such as repaglinide or nateglinide, DPP4 inhibitors;
• High risk: Patients with moderate hyperglycemia (average blood glucose between 150 and 300 mg/dl, A1C 7.5–9.0%), renal insufficiency, advanced macrovascular complications, people living alone that are treated with insulin or sulfonylureas, old age or on other medication that affect mental status;
• Very high risk: where patients have experienced severe hypoglycemia or Hyperosmolar hyperglycemic coma or Diabetic Ketoacidosis within the last 3 months prior to Ramadan or have hypoglycemia unawareness, poor glycemic control, acute illness, pregnancy, kidney failure on dialysis.
The current recommendation is to start with a proper counseling 1-2 months before the onset of Ramadan and to do full assessment which includes fasting glucose level, HbA1c, lipids profile, blood pressure and detection of complications. A session of Ramadan-focused education is also mandatory and is found to minimize the risk of hypoglycaemic events and prevents weight gain during this festive period for Muslims, which potentially benefits metabolic control (4). After that, the physicians should work with their patients to prepare an appropriate and individualized life-style, diet and drug plan.
In terms of medication, dose and timing need to be adjusted and blood glucose need to be frequently monitored by SMBG. Metformin alone can be used safely during the fast with minimal possibility of severe hypoglycemia; however, consensus recommendations suggest the dosage can be modified such that two-thirds of the total daily dose is taken with the sunset meal and the other one-third is taken before the pre-dawn meal. Sulfonylureas should be avoided during Ramadan fasting because of the risk of hypoglycemia. When Insulin is involved, always consider intermediate-acting or long-acting insulin preparations plus short-acting insulin before meal (5).
In my clinical practice, every Ramadan I face a major challenge which is the tendency and the deep desire to fast in most of my patients regardless of their risk status. This is mainly to do with patients’ cultural and religious values and usually it is difficult to modify.
The other challenge is having Ramadan in July, the hottest month of the year in most parts of the Middle East. Furthermore in the northern hemisphere, Ramadan day will be the longest and can go up to 19 hours in some countries. These reflect on the possibility of increasing adverse effects and the need for further education.
Eating healthy food during Ramadan and Eid time is a cornerstone as well as doing light physical activity and proper frequent SMBG testing. Education about how to react to low or high readings and staying in close contact with the physician are all essential strategies to reach the goal of safe fasting for people with diabetes.
1- http://www.pewforum.org/2011/01/27/the-future-of-the-global-muslim-population/ (accessed June 24-2104)
2- http://www.idf.org/diabetesatlas (accessed June 24-2014)
3- 1. Al-Arouj M, Bouguerra R, Buse J, Hafez S, Hassanein M, Ibrahim MA, et al. Recommendations for Management of Diabetes During Ramadan. Dia Care. 2005 Sep 1;28(9):2305–11.
4- 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. Diabet Med. 2010 Mar;27(3):327–31.
5- Hui E, Bravis V, Hassanein M, Hanif W, Malik R, Chowdhury TA, et al. Management of people with diabetes wanting to fast during Ramadan. BMJ. 2010;340:c3053