Background
Hajj is one of the main pillars of Islam and is mandatoryfor 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 andMedina during a specified short period. Hajj among other things involveswalking long distances and camping in desert tents. This also includespilgrim’s presence on the desert plain of Mina, Arafat and Muzdalfa where theyspend most of the time in prayers. Because of large number of people, covering short distances will take along 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 physicalexertion and suffer from medical conditions like diabetes, high blood pressure,kidney and heart disease, these can aggravate if not taken care properly. Theusual temperature during Hajj ranges from 37 to 45 degree Celsius. Thistogether with overcrowding may be associated with some health hazards. DuringHajj, 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 andself-management takes a low priority. Common problems encountered during Hajjinclude chest infections, diarrhoea, dehydration, heart disease and somecommunicable 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 beprolonged). The following health risks should be anticipated especially inpeople with diabetes:
• Low bloodglucose
• Highblood glucose
• Dehydration
• Heatexhaustion and heat stroke
• Chestinfections, diarrhoea, middle east respiratory syndrome
• Footinfections and ulcers
• Heartproblems
Avoid hypoglycemia (low blood glucose)
Low blood glucose is always a risk during Hajj. It isbecause of unusually excessive physical activity, smaller meals, differenttiming of meals from normal, and preference for performing prayer in the holyshrines (which may be quite away from the residence and may delay meal times).Excessive heat during summer season may increase insulin absorption. Peoplegiving insulin with syringes need to know the differences in concentrations ofinsulin available in India and Saudi Arabia. In Saudi Arabia, insulin isavailable as 100 unit vials (means 100 units of insulin in one ml) where as inIndia it is mostly available as 40 unit vials (means 40 units per ml). Thisresults in overdose (and consequent hypoglycemia) if 100 unit insulin is givenwith 40 unit syringe. People using insulin pen devices need not to worry asonly 100 unit cartridges are available in both the countries
The following are the recommendations for people takinginsulin for diabetes:
Beforetaking a long walk (like going for Tawaf, walk between Mina, Arafat, Muzdalfaand Mecca), it is advisable to decrease the insulin dose by 20% and oraldrug by half.
Beforestarting any journey, check your blood glucose, if it is lower than 100 mgs/dltake some bread, if high (>300), give small dose of regular insulin (four tofive units) to cover it.
BeforeTawaf and Saay, consume extra carbohydrate like bread or biscuit.
Alwaystake a mid morning snack like bread, or fruit like apple, pear, orange orstrawberry, or nuts and seeds or low fat yogurt or a bowl of soup to preventsudden fall in blood glucose between breakfast and lunch.
Incase 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 withwater, if possible check blood glucose after 15 minutes. If the person isunconscious and suspected to have low blood glucose, honey should be rubbed onhis gums or a glucagon injection given. After low blood glucose is corrected, asnack 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 increaseblood glucose. In order to avoid this, continue to take insulin or diabetesmedications (usual dose may be decreased by 20%), test blood glucose regularly,if it is >250(especially in type 1 diabetes), test for urine or bloodketones. If one feels sick, he/she should take some carbohydrate containingdrink as suggested above. If one still feels unwell, contact healthcare team.
Avoid Dehydration
Take plenty of water (at least 8 glasses) during day andcarry water bottles with you all the time. Avoid caffeine or sugary drinks. Ifpossible, 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 60degree Celsius; temperature may be further high on hot marble. Walking barefootin hot temperature can cause burn injuries. In addition, cracks can develop insoles due to dry weather and hot temperature. Minor injuries to toes can alsodevelop during Tawaf from stamping. Following measures will prevent footproblems:
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 avoidextra pressure on feet and toes while walking). While walking in mosque, it ispermissible to wear leather socks, which will offer some protection. In orderto avoid dryness, use moisturiser 3 to 4 times daily especially after Wudhu.
Dietary advice
For many pilgrims meals will be served buffet-style, sochose your food carefully. Start your meal with a fresh, well-cleaned salad andvegetables and opt for lean meat and basmati rice dishes, to keep blood sugarlevels under control. Desserts should be avoided as they increase your blood sugarlevels and cause dehydration, instead stick to whole fruits and plenty of fibresuch as pears, apples and strawberries. Always have a snack in mid morning andbefore going for prayers and tawaf.
Kidney and Heart disease
Patients with diabetes and kidney disease should avoiddehydration and avoid self-medication. A pre travel electrocardiogram isadvisable and in case of symptoms like chest pain, palpitation, shortness ofbreath, one should report to health facility as soon as possible.
Things to remember:
Before travel
• Get a pretravel consultation from your treating physician and try to have a good controlof diabetes mellitus and other ailments.
• Informthe caravan manager about your disease and medications.
• Pilgrimsare usually covered with meningitis and influenza vaccination; it is better toget a pneumococcal vaccine as well.
• Prepareadequate medications and place them in separate containers.
• Ifpossible, prepare a cool pack to store insulin. Keep insulin in hand baggage.
• Chooseshoes and sandals with appropriate shape and size and wear these for many days(at home place) before departure to ensure foot comfort.
• Pack yourmedications in carry-on luggage rather than in checked baggage.
During travel
• As for aspossible prevent exposure to direct heat (use umbrella), keep your head andears covered with moist cloth and take water liberally to prevent dehydration.
• Alwayscarry some sugar containing food to be used in case of low blood glucose(honey, dates, jam, glucose biscuits etc).
• Take twounits of fresh fruits per day and avoid fruit juices.
• Drink atleast eight glasses of water daily and carry enough water bottles withyourself.
• If usinginsulin; before Ihram, check your blood glucose by glucometer. If needed, use asmall dose of insulin (if glucose is more than 250 or 300 mgs/dl) or some bread(if glucose is less than 100 mgs/dl).
• Beforeand during long walking, decrease the dose of short and intermediate insulinabout 20% and oral drug by 50%.
• BeforeTawaf and Saay, consume some extra carbohydrate (bread is preferred).
• Walkslowly during Tawaf and Saay, and try to protect your feet from damage by theground tiles or other pilgrims. Avoid walking bare footed as much as possible,use moisturizer liberally.
• In caseof fever, diarrhoea, vomiting or any acute medical condition consult yourmedical 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