Can Diabetic Patients Fast During Ramadan?
.........................................................................................................................

Dr. Yousef Abdullah Al Turki
MBBS, DPHC, ABFM
Associate Professor and consultant family medicine
Family and community medicine department
College of medicine, King Saud University
P.O Box. 28054, Riyadh - 11437, Saudi Arabia
yalturki@ksu.edu.sa
Fax: 4671967
Tel: 4671942

INTRODUCTION

During Ramadan, the ninth month of the Islamic lunar calendar, adult Muslims are required to abstain from taking any food, fluids, or oral drugs from dawn to sunset. Patients with chronic diseases often insist on fasting even though they are permitted not to by Islamic rules^(1,2). Serious complications of fasting from Ramadan have not been well documented in literature, but the most frequently reported is increased risk of hypoglycemia and hyperglycemia in patients with diabetes^(3-12). Despite evidence that many people with long term conditions modify their treatment regimens during Ramadan, many people do not get detailed advice on how to do this safely^(2,4).

Sulphonylureas and insulin tended to increase the risk of hypoglycemia, whereas metformin was associated with less frequent hypoglycemia⁽¹³⁾. Patients with type 2 diabetes may safely fast with close monitoring of blood glucose levels and possible adjustment of medication to avoid hypoglycemia⁽³⁾ Several studies have been published on the effects of fasting in healthy adults, but little is known on the clinical problems during the fast of Ramadan^(1,6,9,12).

The objective of this study is to assess health difficulties facing diabetic patients in fasting during Ramadan at a hospital based primary care clinic, Riyadh, Saudi Arabia.

This is a cross sectional study which was conducted at a hospital based primary care clinic at King Khalid University Hospital(KKUH), in Riyadh, Saudi Arabia. The study was conducted over a 5 month period starting immediately after Ramadan 1427 (from 9th of Shawal 1427 to the end of Safar 1428) 31 October 2006 till 10 march 2007.

All adult male diabetic patients attending a one consultant primary care clinic at KKUH were interviewed during their routine follow up consultation by a consultant in family medicine. All included diabetic patients were interviewed once by the same consultant in family medicine. The clinic schedule was 3 half day clinical sessions/ week during the study period. All diabetic patients were asked to determine how many days already they fasted during Ramadan 1427 and any hypoglycemic attacks during Ramadan. They were also asked to categorize difficulties in fasting during Ramadan as: no difficulty, sometimes, and always. Also patients were asked did they adjust their diabetic medications and did they receive particular health education about adjusting their diabetic treatment during Ramadan.
Also other relevant data such as age, type of DM, duration of DM, type of treatment, and glycosylated haemoglobin HBA1C were recorded in a specific data collection form. Data was analyzed using the statistical package for social science (SPSS) version 11.5.

A total of 204 adult male diabetic patients were included in the study. The majority of patients had type 2 diabetes mellitus (97.1%), and (2.9%) had type 1 diabetes mellitus. (Table 1)
The result of this study shows that the majority of diabetic patients in the study sample (92.2%) had fasted all days of Ramadan (30 days), while 4.4% fasted 29 days. (Table 2).

This study showed that 93.6% of diabetic patients did not have any hypoglycemic attacks during Ramadan fasting. Only 3.9% of diabetic patients had one hypoglycemic attack, 1.5% had two attacks, 0.5% had three attacks, while 0.5% had six attacks. (Table 3)
83.3% emphasized that they had no health difficulties during Ramadan fasting. While 16.2 sometimes had health difficulties during Ramadan fasting (Table 4). Most diabetic patients in this study, 91.6%, had been educated by their treating physicians about fasting in Ramadan and 96.6% of diabetic patients had adjusted their oral hypoglycemic agents and insulin during Ramadan fasting (Table 5).

Medicine is a theoretical and practical science which shari'a (Muslim law) has permitted to be learned and practiced because of its ability to preserve health and ward off maladies and disease from this honored human body⁽¹⁴⁾.
Ramadan fasting is a healthy method for improving coronary heart disease risk factors, since many factors can influence the effects of Ramadan on biochemical and physiologic parameters⁽⁹⁾ . Iatrogenic hypoglycemia is the limiting factor in glycemic management of diabetes. It causes recurrent symptomatic and sometimes, at least temporarily, disabling episodes in most people with type 1 diabetes as well as in many with advanced type 2 diabetes, and is sometimes fatal⁽¹⁵⁾. No study has so far been able to link Ramadan fasting with hypoglycemia in healthy individuals⁽⁹⁾. The results of this study show that the majority of diabetic patients in the study sample (92.2%) had fasted all days of Ramadan (30 days), while 4.4% fasted 29 days. Only one elderly diabetic patient did not fast during all days of Ramadan because of health difficulties he was facing due to advanced type 2 diabetes and co morbidities of advanced unstable cardiac diseases and on multi medications.
Most of the Muslim diabetic patients followed at the primary care clinic in this study were highly concerned and motivated to fast during Ramadan like other healthy people, even though sick people are excused in Islam⁽¹⁾. This study showed that 93.6% of diabetic patients did not have any hypoglycemic attacks during Ramadan fasting. 83.3% emphasized that they had no health difficulties during Ramadan fasting, while 16.2 sometimes had health difficulties during Ramadan fasting. This might be explained because most of the diabetic patients in this study 91.6% had been educated by their treating physicians about fasting in Ramadan and 96.6% of diabetic patients had adjusted their oral hypoglycemic agents and insulin during Ramadan fasting, even though one study done in Saudi Arabia showed that the frequency of lack of knowledge of symptoms of hypoglycemia was around 50% of 1,039 diabetic subjects registered in urban and rural primary health care centers⁽¹⁶⁾. In this study 73% of diabetic patients were on oral hypoglycemic agents, while 23.5% were on insulin, and 3.4% were on diet only. The current study showed that only 36.3% of diabetic patients had glycosylated haemoglobin HBA1C less than 7 which indicates the need for further blood sugar control in diabetic patients to improve the quality of diabetic care and to prevent complications. Other studies showed poor glycemic control in 77% of the diabetic patients by HBA1C level⁽¹⁷⁾.
This study showed that most of the diabetic patients had other cardiovascular risk factors, as 44.1% of them had diabetes and hypertension, and 19.1% had diabetes and dyslipedemia, while only 33.3% of them had only diabetes mellitus. Two studies showed that the effects of fasting during Ramadan on stable patients with cardiac disease are minimal. The majority of patients with stable cardiac disease can fast during Ramadan without significant detrimental effects(6,7) .

One study done in Saudi Arabia showed that the rate of treatment-related misconceptions among primary health care centers registered diabetic patients to be high, and of an important nature. It stresses the need for constant motivation and face to face health education at frequent intervals to encourage better knowledge regarding the disease and to improve compliance with treatment⁽¹⁸⁾
Also different studies emphasized the importance of continuing patient and family education for care of diabetes^(19-21). and to improve the quality of diabetic care and prevent diabetic complications^(22-27).
Diabetes is known to be associated with alterations in metabolic parameters. Muslim type 2 DM patients showed a trend towards better glycemic control following Ramadan fasting⁽²⁸⁾.

In conclusion, the majority of type 2 Diabetic patients fasted during Ramadan without difficulties and most had adjusted their oral hypoglycemic agents.
It is important and essential for primary health care physicians to educate their Muslim diabetic patients before Ramadan fasting, to clarify any misconception about adjustment of their hypoglycemic agents and insulin during Ramadan, and to avoid preventable complications like hypoglycemia which is sometimes fatal. Further community based studies are recommended to study diabetic patients' medical issues during Ramadan.

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