Hajj: A guide for patients

Background

Hajj is one of the main pillars of Islam and is mandatory for all adult Muslims who can afford the journey and are in acceptable health. Hajj involves travel to holy cities in Saudi Arabia in and around Mecca and Medina during a specified short period. Hajj among other things involves walking long distances and camping in desert tents. This also includes pilgrim’s presence on the desert plain of Mina, Arafat and Muzdalfa where they spend most of the time in prayers.  Because of large number of people, covering short distances will take a long time.

What health consequences we should anticipate during Hajj?

Lot of physical and mental effort is required during Hajj. Significant proportion of people performing Hajj are not used to physical exertion and suffer from medical conditions like diabetes, high blood pressure, kidney and heart disease, these can aggravate if not taken care properly. The usual temperature during Hajj ranges from 37 to 45 degree Celsius. This together with overcrowding may be associated with some health hazards. During Hajj, a person’s routine changes as he travels to a place where language, geography, temperature, diet and habits are different from his parent place. People performing Hajj are preoccupied with religious rituals and self-management takes a low priority. Common problems encountered during Hajj include chest infections, diarrhoea, dehydration, heart disease and some communicable diseases.

What are the health issues common in people with diabetes?

Diabetes is a disease where a stable routine (like diet, exercise and medications) is affected significantly in terms of timing of food (may not be taken at routine time) and duration of exercise (could be prolonged). The following health risks should be anticipated especially in people with diabetes:

•             Low blood glucose

•             High blood glucose

•             Dehydration

•             Heat exhaustion and heat stroke

•             Chest infections, diarrhoea, middle east respiratory syndrome

•             Foot infections and ulcers

•             Heart problems

Avoid hypoglycemia (low blood glucose)

Low blood glucose is always a risk during Hajj. It is because of unusually excessive physical activity, smaller meals, different timing of meals from normal, and preference for performing prayer in the holy shrines (which may be quite away from the residence and may delay meal times). Excessive heat during summer season may increase insulin absorption. People giving insulin with syringes need to know the differences in concentrations of insulin available in India and Saudi Arabia. In Saudi Arabia, insulin is available as 100 unit vials (means 100 units of insulin in one ml) where as in India it is mostly available as 40 unit vials (means 40 units per ml). This results in overdose (and consequent hypoglycemia) if 100 unit insulin is given with 40 unit syringe. People using insulin pen devices need not to worry as only 100 unit cartridges are available in both the countries 

The following are the recommendations for people taking insulin for diabetes:

             Before taking a long walk (like going for Tawaf, walk between Mina, Arafat, Muzdalfa and Mecca), it is advisable to decrease the insulin dose by 20% and oral drug by half.

             Before starting any journey, check your blood glucose, if it is lower than 100 mgs/dl take some bread, if high (>300), give small dose of regular insulin (four to five units) to cover it.

             Before Tawaf and Saay, consume extra carbohydrate like bread or biscuit.

             Always take a mid morning snack like bread, or fruit like apple, pear, orange or strawberry, or nuts and seeds or low fat yogurt or a bowl of soup to prevent sudden fall in blood glucose between breakfast and lunch.

             In case of symptoms of low blood glucose (like exhaustion, headache, palpitation, tremor, sweating, confusion person should be treated with one of the following: honey (one table spoon); dates (2-3); fruit juice (half a glass); sports drink (100 ml); glucose tablets; jelly sweets or 2-3 glucose biscuits with water, if possible check blood glucose after 15 minutes. If the person is unconscious and suspected to have low blood glucose, honey should be rubbed on his gums or a glucagon injection given. After low blood glucose is corrected, a snack like a slice of a toast or sandwich or a bowl of cereal should be taken.

Avoid High blood glucose

Missing of proper medications like insulin can increase blood glucose. In order to avoid this, continue to take insulin or diabetes medications (usual dose may be decreased by 20%), test blood glucose regularly, if it is >250(especially in type 1 diabetes), test for urine or blood ketones. If one feels sick, he/she should take some carbohydrate containing drink as suggested above. If one still feels unwell, contact healthcare team.

Avoid Dehydration

Take plenty of water (at least 8 glasses) during day and carry water bottles with you all the time. Avoid caffeine or sugary drinks. If possible, carry an umbrella with and use frequent water spray to keep one cool. In case of diarrhoea, consult medical team for quick management of dehydration.

Be aware of Foot problems

In summer months, ground temperature may go above 50 to 60 degree Celsius; temperature may be further high on hot marble. Walking barefoot in hot temperature can cause burn injuries. In addition, cracks can develop in soles due to dry weather and hot temperature. Minor injuries to toes can also develop during Tawaf from stamping. Following measures will prevent foot problems:

Make sure that shoes, sandals you wear are of correct size, shoes should be “worn in” before using extensively to prevent undue rubbing. Shoes should have a good ankle support and wide enough front part (to avoid extra pressure on feet and toes while walking). While walking in mosque, it is permissible to wear leather socks, which will offer some protection. In order to avoid dryness, use moisturiser 3 to 4 times daily especially after Wudhu.

Dietary advice

For many pilgrims meals will be served buffet-style, so chose your food carefully. Start your meal with a fresh, well-cleaned salad and vegetables and opt for lean meat and basmati rice dishes, to keep blood sugar levels under control. Desserts should be avoided as they increase your blood sugar levels and cause dehydration, instead stick to whole fruits and plenty of fibre such as pears, apples and strawberries. Always have a snack in mid morning and before going for prayers and tawaf.

Kidney and Heart disease

Patients with diabetes and kidney disease should avoid dehydration and avoid self-medication. A pre travel electrocardiogram is advisable and in case of symptoms like chest pain, palpitation, shortness of breath, one should report to health facility as soon as possible.

Things to remember:

Before travel

•             Get a pre travel consultation from your treating physician and try to have a good control of diabetes mellitus and other ailments.

•             Inform the caravan manager about your disease and medications.

•             Pilgrims are usually covered with meningitis and influenza vaccination; it is better to get a pneumococcal vaccine as well.

•             Prepare adequate medications and place them in separate containers.

•             If possible, prepare a cool pack to store insulin. Keep insulin in hand baggage.

•             Choose shoes and sandals with appropriate shape and size and wear these for many days (at home place) before departure to ensure foot comfort.

•             Pack your medications in carry-on luggage rather than in checked baggage.

During travel

•             As for as possible prevent exposure to direct heat (use umbrella), keep your head and ears covered with moist cloth and take water liberally to prevent dehydration.

•             Always carry some sugar containing food to be used in case of low blood glucose (honey, dates, jam, glucose biscuits etc).

•             Take two units of fresh fruits per day and avoid fruit juices.

•             Drink at least eight glasses of water daily and carry enough water bottles with yourself.

•             If using insulin; before Ihram, check your blood glucose by glucometer. If needed, use a small dose of insulin (if glucose is more than 250 or 300 mgs/dl) or some bread (if glucose is less than 100 mgs/dl).

•             Before and during long walking, decrease the dose of short and intermediate insulin about 20% and oral drug by 50%.

•             Before Tawaf and Saay, consume some extra carbohydrate (bread is preferred).

•             Walk slowly during Tawaf and Saay, and try to protect your feet from damage by the ground tiles or other pilgrims. Avoid walking bare footed as much as possible, use moisturizer liberally.

•             In case of fever, diarrhoea, vomiting or any acute medical condition consult your medical team promptly instead of waiting in your residence.

Short summary:

A good planning and proper knowledge will help this spiritual pilgrimage to be as safe as possible. Avoid excessive heat, keep yourself well hydrated, take some snack before exercise and finally take care of your feet.

Dr. Bashir Ahmad Laway is  Professor & Head, Endocrinology, SKIMS