:rose: :rose: :rose: DIABETES AND FASTING IN RAMADHAAN:rose: :rose: :rose:
The Prophet, sallallahu alayhi wasallam, said, "Verily, Allah requires that we do everything we do as perfectly as possible." (Muslim)
The fast of Ramadhaan is undertaken by about a billion Muslims annually. During the month of Ramadhan fluid and food are allowed only at night; the dietary pattern changes to one large meal at sunset (Iftaar) and one light meal before dawn (Suhur) and the intake of carbohydrates usually rises. Patterns differ, of course. Some people eat a high-caloric snack immediately after breaking their fast, with a larger meal an hour or two later and small tidbits throughout the night.
A recent article. pointed out a concise instruction for Muslim diabetic patients during the month of Ramadhan; it asserted that diabetic patients be evaluated before Ramadhan to assess their physical well-being, metabolic control, and ability to fast. Often, patients with diabetes do not see themselves as having a serious illness and so observe the Ramadhan fast. Health practitioners must then counsel them on how to fast without endangering their health. The usual concern is that fasting may precipitate hypoglycaemic episodes, when the patient is on medication. Hyperglycaemia with or without ketoacidosis can also be troublesome during fasting, through excessive eating when the fast is broken. Some patients arbitrarily reduce dosages or even stop taking their medication completely. The contraindications to fasting by diabetic patients include:
All brittle type 1 (insulin dependent) diabetic patients; Poorly controlled diabetic patients either type 1 or type 2 (non-insulin dependent) diabetes; diabetic patients known to be noncompliant in terms of following advice on diet, oral hypoglycemic agents, or insulin; diabetic patients with serious complications, e.g., unstable angina or uncontrolled hypertension; patients with diabetic ketoacidosis; pregnant diabetic patients; and diabetic patients with intercurrent infections.
As part of overall education, a Muslim diabetic patient should be educated about special problems that may occur during fasting, as well as any therapeutic adjustments that may become necessary. However, despite the theoretical hazards of fasting, in practice few complications seem to arise.
* In patients controlled oil diet and oral hypoglycaemic agents alone, fasting may even prove beneficial through weight loss.
Dietary principles should be reinforced. It is a common practice among most Muslim communities to consume large quantities of fried foods and carbohydrate-rich meals during the time of breaking fast or later. Patient should be warned of the deleterious effects such could have on diabetes control. It would be a rather drastic step to forbid such foods, and therefore, a small amount may be allowed to improve general compliance.
* patients controlled oil diet alone should try to space meals equally over the non-fasting period to avoid gorging and to make the pre-dawn meal the major meal of the day.
* The safety of fasting for patients with type 2 diabetes has been clearly shown by experiments. However, quite often, dosage adjustments of an oral hypoglycemic agent become necessary.
* Patients on oral hypoglycaemic agents need to be advised on how to change their daily doses. However, if a patient is on chlorpropamide, it should be stopped and replaced with a shorter-acting preparation. If he or she is on a 2nd- or 3rd-generation sulfonylurea (e.g. glibenclamide, gliclazide, or glipizide), it should be taken only on breaking the fast in the evening (iftaar) and not at dawn (suhur); if on tolbutamide or a biguanide (met formin), then the morning dose may also be taken if the patient is on a twice-daily regimen, with the proviso that the smaller dose be taken before suhur; and if on a combination of Sulfonylurea and Biguamide, then both should be taken at iftaar, but the latter only at suhur.
* The largest and most thorough study looked at 542 non-insulin-dependent diabetics treated with Glibenclamide (Daonile or Euglucon) in Morocco. A randomized controlled trial of two regimens was conducted, with a comparison group of diabetics who chose not to fast. None of the laboratory values differed significantly between the three groups; nor was there a difference in the incidence of hypoglycaemia. The findings of this study suggest that Glibenclamide was effective and safe for patients with non-insulin*dependant diabetes who fasted during Ramadhan, other data support this interpretation.
In insulin-treated patients, the safety of fasting during Ramadhan must be carefully assessed, since many require frequent snack meals to avoid hypoglycaemia. Home glucose monitoring and testing for ketones must be encouraged not only to prevent hypoglycemia but also to prevent overeating.
Therefore, type 1 diabetic patients are generally advised not to fast because of possible hypoglycaemia or problems with control. However, such advice is often not followed. Of interest in this regard is a recent study that established the safety of fasting in relatively stable type 1 diabetic patients.
The ideal regimen for such patients is the short-acting insulin (regular) before meals with a long-acting insulin at bedtime. While fasting, they should take a short-acting insulin before the dawn meal and after the evening meal and an intermediate-acting insulin (e.g., Protaphane or Humulin L) at bedtime. However, if they are unwilling to change and are on the conventional twice-daily insulin regimen, then during Ramadhan they should take the usual evening dose of short-acting insulin only at dawn with no intermediate acting insulin and in the evening (iftaar) the usual morning dose of short-acting and intermediate-acting insulin.
Insulin-requiring type 2 diabetic patients should follow the same regimen as outlined for type 1 diabetic patients.
Home blood glucose monitoring, which is now regarded as an important prerequisite in the management of insulin treated diabetic patients, should be mandatory in those insulin-treated patients who wish to fast. This way, a close watch could be kept on overall control, as well as on hypoglycemic episodes that may require adjustments to insulin dose or termination of the fast. Diabetic patients should be advised that neither the pinprick required to do home blood glucose monitoring nor injecting oneself with insulin will break the fast.
During Ramadhan, control should continue to be assessed on the basis of home blood glucose monitoring, as well as clinic-based tests. Investigation should be made of hypoglycemic episodes or very high blood glucose levels, and appropriate dose adjustments should be made or the patient may be advised to discontinue fasting.
After Ramadhan, the patient's therapeutic regimen will need to be changed back to what it was previously. An overall evaluation will also be required.
By Khalid Kalantan, MD, ABFM
Assistant Professor, University of Toronto
THE BOTTOM LINE
I strongly advise all Muslim diabetic brothers and sisters to consult their family doctors at least two weeks prior to Ramadhan, to make sure that they can fast safely and to select strategy for diabetes control. Here is a quick guideline:
* Make the, pre-dawn meal the major meal of the day
* Space meals equally over the non-fasting period.
* On sulphonylurea
* On single daily dose: take dose with the sunset meal.
* On more than a once-daily regimes: switch the morning dose (plus any Midday dose) with that taken at sunset.
* Fasting not recommended in those prone to ketoacidosis or with wide swings in blood glucose.
* On a single daily dose: change to twice daily dose.
* On a twice daily dose: take half or one-third of morning insulin and take usual evening dose.
Al-Jumuah vol.10 issue 8/9