DUHS-Seminar
A public awareness program for diabetic patients was organized by National Institute of Diabetes & Endocrinology at Ojha Campus, Dow University of Health Sciences, Karachi
Speaking on this occasion, Director of the Institute, Professor M. Zaman Shaikh, informed that it is estimated that there are 1.1–1.5 billion Muslims worldwide, comprising 18–25% of the world population and that some 40–50 million people with diabetes worldwide fast during Ramadan.
In EPIDIAR (Epidemiology of Diabetes and Ramadan – 1422/2001) Study which was done in 13 Islamic countries, out of 12,243 people with diabetes, 43% of patients with type 1 diabetes and 79% of patients with type 2 diabetes were keeping fast during Ramadan. Frequencies of acute complications were higher in them.
The duration of the daily fast may range from a few hours to more than 20 hours, depending upon geographical location and season of the year in different countries of the world.
Many patients with diabetes who are otherwise unfit, insist on fasting during Ramadan, thereby creating a medical challenge for themselves and their physicians.
For example, fasting, especially among patients with type 1 diabetes with poor glyceamic control, is associated with multiple risks.
A large epidemiological study conducted in 13 Islamic countries on 12,243 individuals with diabetes who fasted during Ramadan showed a high rate of acute complications
Some of complications occurring in diabetic patients during Ramdan are following:
Hypoglycemia (Very Low Blood Sugar): The largest dataset is the recent EPIDIAR study, which showed that fasting during Ramadan increased the risk of severe hypoglycemia (defined as hospitalization due to hypoglycemia), 4.7-fold increase in patients with type 1 diabetes and 7.5-fold increase in patients with type 2 diabetes.
Hyperglycemia (Very High Blood Sugar): The extensive EPIDIAR study showed a fivefold increase in the incidence of severe hyperglycemia (requiring hospitalization) during Ramadan in patients with type 2 diabetes and approximate threefold increase in the incidence of severe hyperglycemia with or without ketoacidosis in patients with type 1 diabetes.
Diabetic ketoacidosis coma: Patients with diabetes, especially those with type 1 diabetes, who fast during Ramadan are at increased risk for development of unconsciousness due to diabetic ketoacidosis, particularly if they are grossly hyperglycemic before Ramdan. The risk for diabetic ketoacidosis may be further increased due to excessive reduction of insulin dosages based on the assumption that food intake is reduced during the month.
Dehydration and thrombosis: Limitation of fluid intake during the fast, especially if prolonged, is a cause of dehydration. The dehydration may become severe in hot and humid climates and among individuals who perform hard physical labor, all conditions that result in excessive perspiration. In addition, hyperglycemia can result in diuresis (excessive urination) and contribute to volume and electrolyte depletion. Syncope, falls, injuries, and bone fractures may result from hypoglycemia and the associated low blood pressure. Increased blood viscosity secondary to dehydration may enhance the risk of thrombosis.
General considerations
Frequent monitoring of glycemia: It is essential that patients have the means to monitor their blood glucose levels multiple times daily. This is especially critical in patients with type 1 diabetes and in patients with type 2 diabetes who require insulin.
Nutrition: To remain healthy, a diabetic person must eat from all the major food groups. The quantity of food consumed should be less than the routine days.
–The fruit consumption should be increased.
–Take sufficient amount of water between the bed time and IFTAR to avoid
Dehydration.
–Take enough quantity of vegetables during the meal.
–Take fruits after meal.
–Try to avoid spicy food.
–Stay away from caffeine, including tea, coffee and colas.
–Stay away from oily and fried things like pakoras and samosas.
About 50–60% of individuals who fast maintain their body weight during the month, while 20–25% either gain or lose weight, occasionally, the weight loss may be excessive (>3 kg). The common practice of ingesting large amounts of foods rich in carbohydrate and fat, especially at the Iftar time, should be avoided.
Exercise: Normal levels of physical activity may be maintained. However, excessive physical activity may lead to higher risk of hypoglycemia and should be avoided, particularly during the few hours before the sunset meal
Breaking the fast: All patients should understand that they must always and immediately end their fast if hypoglycemia (blood glucose of <60 mg/dl occurs, since there is no guarantee that their blood glucose will not drop further if they wait or delay treatment. Finally, the fast should be broken if blood glucose exceeds 300 mg/dl. Patients with type 1 diabetes, especially if “brittle” or poorly controlled, are at very high risk of developing severe complications and should be strongly advised to not fast during Ramadan. In addition, patients who are unwilling or unable to monitor their blood glucose levels multiple times daily are at high risk and should be advised to not fast. Subcutaneous insulin pump management is an appealing alternative strategy; however, it is more expensive and still requires frequent blood glucose monitoring. Still they are not available in Pakistan.
Management of patients with Type 2 diabetes
Diet-controlled patients.
In patients with Type 2 diabetes who are well controlled with diet alone, the risk associated with fasting is quite low. They should be encouraged to keep fast.
Patients treated with oral agents: They may also keep fast; however, they should take higher dose of tablets at the time of Iftari and lower dose at the time of Sehri. Some oral drugs are comparatively safer during fasting. Patients should seek advice from their doctors regarding changing the dose and type of tablets.
Patients Using Insulin: Patients on single dose of insulin in 24 hours may keep fast. However it is risky for patients to keep fast who are on more than two doses of insulin in a day. Again some insulin’s are safer during Ramadan, they are usually short-acting, analogue type of insulins.
Management of hypertension and dyslipidemia: High blood pressure and high cholesterol should be taken care of during Ramadan. Because due to dehydration, there is tendency of low blood pressure and because of high intake of traditional food items at Sehri and Iftar like Samosa, Roles, Pakora, Khajla, Sweet Dahi Bara there is tendency of high cholesterol.
In general, patients with type 1 diabetes should be strongly advised not to fast. Patients with type 1 diabetes who have a history of recurrent hypoglycemia or hypoglycemia unawareness or who are poorly controlled are at very high risk for developing severe hypoglycemia. The management plan of diabetic patients keeping fast must be highly individualized