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The Islamic faith is characterized by five central pillars: the public declaration of one’s faith, five daily prayers, an annual tax to the poor, a pilgrimage to Mecca, and annual fasting. Muslims fast together during the month of Ramadan, which is the ninth month of the Islamic lunar calendar and will next occur from August 1st-30th, 2011. The month begins 10 to 11 days earlier each year in the solar calendar and may occur during different seasons of the year. During Ramadan, Muslims refrain from food, oral medications, drinking, smoking, and sexual activity between the hours of dawn (Suhur) and sunset (Iftar). The purpose of fasting is to seek purification and to celebrate the month in which the verses of the Qur’an were revealed. The children, elderly, travelers, and sick are discouraged from participating in the fast.
Such an extensive fasting period is expected to produce metabolic alterations. Fasting increases the body’s glucagon and catecholamine concentrations while decreasing the concentration of insulin and thus promotes glycogenolysis, gluconeogenesis, and fatty acid oxidation. Fasting can potentially lead to several adverse outcomes, including hypoglycemia, hyperglycemia, ketogenesis, and hypovolemia. Physicians are encouraged to learn about and discuss the physiologic effects of fasting with their patients to prevent bad outcomes.
Diabetics require careful monitoring during Ramadan, as these patients are predisposed to complications, given their pre-existing glucose imbalances. In 1995, an international consensus meeting of physicians and researchers was held in Morocco to establish guidelines regarding participation in the fast. The following groups were advised to refrain from fasting: patients with type 1 diabetes, patients with unstable type 2 diabetes, patients with complicated diabetes, pregnant women with diabetes, and elderly patients with diabetes. Continued monitoring was recommended before, during, and after Ramadan for fasting diabetics.
The landmark Epidemiology of Diabetes and Ramadan (EPIDIAR) study examined diabetic Muslims in 13 countries during Ramadan. After the end of Ramadan in 2001, 100 medical practitioners were selected in each of the countries to enroll patients. Patients were included if they had either type 1 or type 2 diabetes and had the ability to respond to a short questionnaire given in interview form by the practitioner. A total of 12 243 patients were included in this study, of which 8.7% had type 1 diabetes. Fasting for at least 15 days during the month of Ramadan was reported by 42.8% of type 1 diabetics and 78.7% of type 2 diabetics. The number of episodes of severe hypoglycemia requiring hospitalization per month was significantly higher during Ramadan compared to other months for type 1 diabetics (0.14 vs. 0.03, 4.7 fold increase, p=0.017) and for type 2 diabetics (0.03 vs. 0.004, 7.5 fold increase, p<0.0001). The increased incidence of severe hypoglycemia in type 1 and type 2 diabetics was attributed to physical activity and, ironically, medication adjustments. Among the patients with more hypoglycemic episodes, practitioners had adjusted oral medications in 38.4% and insulin in 55.3% compared to the group with fewer hypoglycemic episodes in which practitioners had adjusted oral medications in 19.7% and insulin in 36.7%. Other studies have found a 2-4% mortality rate from hypoglycemia in type 1 diabetics in the overall population, but no convincing data regarding mortality from hypoglycemia in type 2 diabetics.
Given the difficulties regarding medical management of diabetes during Ramadan, recent studies have focused on effective ways to perform medication adjustments during the fasting period. Oral medications that increase insulin sensitivity are generally safer to use than others. Specifically, thiazolidinediones and metformin are acceptable to continue in fasting patients. The daily metformin dose should be divided, with one-third given before dawn and two-thirds given before the meal at sunset. Sulfonylureas may cause hypoglycemia and are not recommended for use in fasting patients. The short-acting insulin secretagogues, such as repaglinide, may be safe to use.
If a patient with type 1 diabetes continues to desire to fast despite advice from the physician, there are several ways to adjust the insulin dose to accommodate two large meals per day. A total of 70% of the patient’s usual insulin dose can be given. Sixty percent of this dose should be taken after sunset in the form of long-acting glargine and 40% should be taken in two divided doses before meals at dawn and sunset as one of the rapid-acting forms of insulin: aspart, glulisine, or lispro. Another option is to give 100% of the patient’s usual morning dose of 70/30 pre-mixed insulin before dawn and then only 50% of the usual evening dose after sunset. Diabetic patients must check their glucose levels regularly and end the day’s fast early if levels are less than 60 mg/dL or greater than 300 mg/dL.
The EPIDIAR study found that 50% of diabetic patients participating in the fast did not change their lifestyles during the month. Those who did, however, decreased their daily physical activity, sleep duration, and food and fluid intake. Ramadan provides an opportunity for physicians to promote healthy lifestyle changes such as exercise, quality sleep, a balanced diet, and smoking cessation, which their Muslim patients can adhere to throughout the year. Several studies have found that fasting during Ramadan is associated with an increase in HDL- cholesterol in both diabetics and non-diabetics.
The London Department of Health funded the production of an information packet for fasting Muslims which was produced by Communities in Action and may be found at their website. The information on physiology and nutrition is accessible to patients in the form of diagrams and nonscientific language. The nutritional advice is given in the context of a South Asian or Middle Eastern diet as opposed to a Western one. Information is provided regarding prevention of gastroesophageal reflux, headaches, dehydration, and diabetic complications during the fast.
Sana Shah is a 4th year medical student at NYU School of Medicine
Reviewed by Muhibur Rahman, RPA-C and Michael Tanner, MD Associate Editor, Clinical Correlations
Image courtesy of Wikimedia Commons
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