The first International Congress on "Health and Ramadan", held in Casablanca in 1994, entered 50 research papers from the world over, from Muslim and non-Muslim researchers who have done extensive studies on the medical ethics of fasting.  While improvement in many medical conditions was urged, however in no way fasting was reported to worsen any patients' health or baseline medical condition. 

  Around 1.5 billion people worldwide (25% of the world’s population) are Muslims. The popula¬tion-based Epidemiology of Diabetes and Ramadan (EPIDIAR) study (involv¬ing 12 243 diabetics in 13 countries) found that about 43% of people with type 1 dia¬betes and 79% of people with type 2 diabetes fast during Ramadan. Based on a worldwide prevalence of 4.6%, we can estimate that up to 50 million Muslim people with diabetes world-wide fast. Qur’an specifically exempts people with a medical condition from the duty of fasting (Sura Baqra). Nevertheless, many people with diabe¬tes insist on fasting during Ramadan.

Fasting should be avoided in
 Type 1 diabetes (Thin subjects usually children, who required insulin from beginning)
 
b. Type 2 diabetes (adults, obese) with
1. High blood glucose (hyperglycemia)
2. Brittle diabetes
3. Insulin pump users
4. Three or four doses of insulin a day
5. Keto-acidosis
6. Hypoglycemia
7. Thrombosis
8. Advanced diabetic complications

Anticipated complications
 Hypoglycaemia (Low blood sugar):Decreased food intake can lead to hypoglycaemia and it accounts for 4% of deaths in type 1 diabetics. It is infrequent in type 2 diabetes.

Hyperglycaemia (High blood sugar):The EPIDIAR study demonstrat¬ed a five-fold increase in the incidence of severe hyperglycaemia (requiring hospitalization) during Ramadan in people with type 2 diabetes perhaps due to excessive reductions in blood glucose-lowering medications. Patient observes increase in thirst, urination and appetite.
 
Diabetic ketoacidosis
Diabetic ketoacidosis (type of diabetic coma), can occur particularly if uncontrolled. The risk is increased due to excessive reduction of insulin.
People with diabetes who fast during Ramadan are at increased risk for developing diabetic ketoacidosis.

Dehydration and thrombosis
Dehydration due to reduced intake of fluids may become severe in hot and humid climates as we have presently in the valley. Increased blood viscosity as a result of dehydration may exacerbate the risk of thrombosis and dehydration may cause fainting, falls and fractures.

General guidelines

 Frequent monitoring of blood glucose
Regular self monitoring of blood glucose (SMBG) several times throughout the day, every day, by meters is essential. Blood glucose at 2-4 pm should be equivalent to fasting and should be kept 70-130 mg/dl. Exercise caution if less than 100 mg/dl and in case of hypoglycemic symptoms they should break the fast.

 Nutrition
People should maintain a healthy and balanced diet during Ramadan. In the non Ramadan meal pattern is to be 3+3 i.e. three major and three minor meals. The non-caloric fluid intake be increased during the non-fast¬ing hours. The Sehri be taken as late as possible before the start of the daily fast and meals between iftar and sehri could be increased in number.

 Physical activity
Normal levels of physical activity can be maintained and exercise should be preferred after Iftar or Sehri but not before Iftar to avoid hypoglycaemia. If Taraweh prayers (long prayer at the time of Isha) are per¬formed, they should be considered a part of a person’s daily physical activ¬ity programme.
 
 Breaking the fast
You should end fast immediately if blood glucose reaches  :
* dramati¬cally–60 mg/dl or lower
* 70 mg/dl in the first few hours after the start of the fast, especially if insu¬lin, sulfonylureas, or miglitinides are taken at the Sehri.
* excessively-300 mg/dl.

 Assessment and counseling
Before the start of medical assessment and educational counseling should be done in all who wish to fast.

 Medical assessment
Ideally 1-2 months before Ramadan, involves specific attention to overall well-being and to the control of blood glucose, blood pres¬sure, and lipids. After appropriate blood tests the medical status should be discussed with the physician.

Conclusions 
* The crucial decision to fast should be made after thorough discussion with the the concerned physician. Highly individualized management plan, and close follow-up is essential.
* Further research is needed to help ex¬pand our knowledge of the risks and management issues related to fasting in people with diabetes.
* Interventional studies can help define new approach¬es that minimize the complications as¬sociated with fasting.

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Lastupdate on : Wed, 1 Sep 2010 21:30:00 Mecca time
Lastupdate on : Wed, 1 Sep 2010 18:30:00 GMT
Lastupdate on : Thu, 2 Sep 2010 00:00:00 IST