Diabetes mellitus epidemic has taken the World by share shock. Today Diabetes affects an estimated 285 million people worldwide, and that number is expected to reach 438 million by the year 2030. Two-thirds of all diabetics live in low- to middle-income countries especially Asia. Muslims constitute around 18-25% of world population. Around 79% Muslim diabetics (reaching a whooping figure of 40 to 50 million) fast during the holy month of Ramadan, thereby, creating a challenge for themselves and their physicians.
During the last two decades, a better understanding of pathophysiological changes during Ramadan fasting in diabetic patients has provided a few guidelines on how to advice diabetics who want to fast. Several laboratory parameters like serum creatinine, uric acid, blood urea nitrogen, protein, albumin, liver enzyme values do not show significant changes during the fasting period. Slight non-significant increases in some biological parameters may be due to dehydration and metabolic adaptation and have no clinical presentation. In general, HbAIC values (an important parameter to assess control of metabolic status in diabetics) show no change or even improvement during Ramadan.
Physicians working with Muslim diabetics should employ certain criteria to advise their patients regarding the safety of Ramadan fast. It is believed that fast should be forbidden in diabetics under following conditions: (i) All brittle type I diabetic patients (on Insulin therapy); (ii) Poorly controlled type I or type II diabetic patients (markedly elevated blood glucose values or HbA1C above 12 percent); (iii) Diabetic patients known to be not compliant on diet/drug regimens and daily activity; (iv) Diabetic patients with serious complications such as unstable angina or uncontrolled hypertension; (v) Patients with a history of diabetic ketoacidosis; (vi) Pregnant diabetic patients; (vii) Diabetic patients with inter-current infections; (viii) Elderly patients with any degree of alertness problems; (ix) Diabetics with two or more episodes of hypoglycaemia and/or hyperglycemia during Ramadan.
Fasting should be encouraged in those diabetics who are overweight and on anti-diabetic pills or diet advice alone (except pregnant or nursing mothers) and in whom diabetes is stable with weight levels 20% above the ideal weight or body mass index (body weight, kg/height, meters squared) greater than 28.
Diabetics should be advised on assessment of physical well being; assessment of metabolic control; adjustment of the diet protocol for Ramadan fasting; adjustment of the drug regimen e.g. change long-acting hypoglycaemic drugs to short-acting drugs to prevent hypoglycaemia; encouragement of continued proper physical activity; recognition of warning symptoms of dehydration, hypoglycaemia and other possible complications. It is important that patients with diabetes who fast should not indulge in dietary indiscretion during the non- fasting period as it can lead to the tendency towards hyperglycemia and weight gain. It has been emphasized that Ramadan fasting benefits appear only in patients who maintain their appropriate diets. Thus, in order to optimize control, diabetics must be reminded to abstain from the high-calorie and highly refined foods prepared during this month.
Specific advice of oral anti-diabetics should be as follows:-Metformin: Fasting can be allowed safely, because this drug does not cause significant drop in blood glucose to below normal range. Two third of the drug should be given immediately before sunset meal (Iftar) and one-third before predawn meal (Sahoor). Glitazones: These drugs do not cause hypoglycaemia hence no change in dose is required. Sulfonylureas: Drugs like glibenclamide is known to cause excessive hypoglycaemia and preferably be avoided. Two drugs have been found to cause less hypoglycaemia during fasting include Gliclazide and Repaglinide. Sitagliptin: No changes in the dosage are required, usual morning dose to be taken at Iftar timing.
If a diabetic who is on insulin therapy chooses to observe fast, insulin therapy needs to be readjusted either as three-dose insulin regimen (two doses before meals -sunset and Dawn- of short-acting insulin and one dose in the late evening of intermediate-acting insulin) or two- dose insulin regimen (evening insulin-combined with short-acting and medium-acting insulin equivalent to the previous morning dosage, and a pre-dawn insulin consisting only of a regular dosage of 0.1-0.2 unit/kg). Home blood glucose monitoring should be performed just before the Iftar (sunset meal) and three hours afterwards. It should also be performed before the Sahoor (pre-dawn meal) to adjust the insulin dose and prevent any hypoglycaemia and post-prandial hyperglycemia following over-eating.
Ethical questions from fasting Muslim patients include: (i). Can we have finger-stick blood drawn for blood sugar? (Answer-yes); (ii). Can we use mouthwash during fasting? (Answer-yes); (iii).Can we take medicine during fasting? (Tablet-no, patch-yes, inhaler-yes, injection-no); (iv).When should a diabetic break his fast before Iftar? (When blood glucose is less than 60 or over 400).

Prof. M. S. Khuroo is Former Director, Professor & Head Gastroenterology and Chairman Department of Medicine, Sher-I-Kashmir Institute of Medical Sciences, Soura, Srinagar. Reach him at Khuroo@yahoo.com.

Lastupdate on : Thu, 2 Aug 2012 21:30:00 Makkah time
Lastupdate on : Thu, 2 Aug 2012 18:30:00 GMT
Lastupdate on : Fri, 3 Aug 2012 00:00:00 IST