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VOL: 99, ISSUE: 28, PAGE NO: 26

Advising patients with diabetes about fasting during Ramadan

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Fasting in the month of Ramadan represents a recurring annual event in the life of a practising Muslim. It is important because it is one of the five Pillars of Islam. Many patients with diabetes will want to take part in this event and nurses with a good understanding of its importance and knowledge of how to manage diabetes can assist in ensuring that this is safely undertaken.

Fasting in the month of Ramadan represents a recurring annual event in the life of a practising Muslim. It is important because it is one of the five Pillars of Islam. Many patients with diabetes will want to take part in this event and nurses with a good understanding of its importance and knowledge of how to manage diabetes can assist in ensuring that this is safely undertaken.

Ramadan fasting

The time of observance of this holy month varies each year as the Muslim calendar is based on the lunar cycle. This year Ramadan will commence in third week of August. During this month food and fluids are allowed only at night and so fasting extends from dawn until sunset, a period that varies by geographical location and season. In summer months and northern latitudes, the fast can last up to 18 hours.

While observing Ramadan the dietary pattern changes to one large meal at sunset called ‘Iftaar’ and a light meal before dawn called ‘Sahur’. However, these eating patterns differ with culture and area. For example, some people eat a high-calorie snack immediately after breaking their fast, followed by a larger meal an hour or two later and small snacks throughout the night; while others eat a larger meal immediately on breaking the fast.

Ramadan is a month of fasting not merely to abstain from food, drinks and smoking but also to practise discipline, realise and atone for past sins and reaffirm one’s faith in religion, the self and humanity (Arif, 1992). The experiences of fasting are intended to remind Muslims of the plight of the impoverished. During Ramadan Muslims take stock of their wealth and take great pleasure in giving to charity.

Fasting in Ramadan is obligatory for every practising Muslim adult. However, if an individual is ill, then he or she is exempted from fasting. This means that people with diabetes could be exempted from fasting. They are, however, often loathe to accept the exemption because of the status of the Ramadan fast - Muslims who have diabetes often want to be able fast so that they may live a spiritually fulfilling life (Katibi et al, 2001).

The physiology of fasting

Historically, studies have shown that if managed properly by health care professionals, Ramadan fasting can be undertaken successfully by Muslims with diabetes (Belkhadir et al, 1993). Recent studies have confirmed this and suggested that management before, during and after the month of Ramadan is vital to ensure that patients with diabetes who wish to fast do so safely (Sulimani et al, 1998; Omar and Motala, 1997).

The two types of diabetes - type I, insulin-dependent diabetes and type 2, non-insulin-dependent diabetes - can both be problematic for people who are fasting.

Management of medication

Belkhadir et al (1993) conducted a trial study in Casablanca and Rabat, Morocco, on 591 patients with diabetes to determine the efficacy of glibenclamide regimens in non-insulin dependent patients with diabetes who were fasting during Ramadan compared with those who were not fasting. The results showed no significant differences between the groups in fructosamine concentration, percentage of glycated haemoglobin or number of hypoglycaemic events during Ramadan.

The conclusion drawn was that glibenclamide was effective and safe for patients with non-insulin dependent diabetes. However, Gold et al (1993) reported that Belkhadir et al’s study (1993) contained several methodological deficiencies resulting in the study being inconclusive and advised health care professionals not to be complacent about managing patients with diabetes during Ramadan. 

Katibi et al (2001) have indicated no major problems with blood sugar levels when there are carefully managed changes in the dosage of hypoglycaemic agents. They recommend switching the morning dose to the evening as this is when the fast is broken and the patient starts to eat. For people with stable type I diabetes who wish to fast, the evening short-acting insulin should be taken at dawn and the usual morning dose of insulin should be taken in the evening when the fast is broken.

 This is reinforced by Kalantan (2002) who suggests the ideal regimen for patients with type I diabetes while fasting is to take the short-acting insulin before the dawn meal and after the evening meal and intermediate-acting insulin at bedtime. But if patients are unwilling to change, then the usual evening dose of short-acting insulin should be given at dawn with no intermediate-acting insulin, and the usual morning dose of short-acting and intermediate-acting insulin should be given in the evening.

Ramadan diet

Muslims generally consume large quantities of fried and sugary foods when they break their fast or during the night. This can be a problem for the management of patients with diabetes; their diet during the non-fasting period (at night) could contribute to hyperglycaemic attacks. It can also lead to weight gain as patients with diabetes reduce their daily activities for fear of hypoglycaemic attacks (Sulimani, 1991). Patients with diabetes need to be advised of the effects of eating such types of foods. However, Omar and Motala (1997) state that: ‘It would be a rather drastic step to forbid such foods, and, therefore, a small amount may be allowed to improve general compliance.’ 

Athar (2002) suggests that a diet sheet recommending appropriate traditional foods and some Western-style foods, along with educational programmes before Ramadan, can achieve a successful and safe fast. 

Patient education

Azizi and Siahkolah (1998) and Kalantan (2002) regard home blood glucose monitoring as an important prerequisite in the management of patients whose diabetes is treated with insulin. In this way, a close overall watch can be kept and adjustments to the insulin dose can be made as and when required. In addition, clinic-based blood tests should be performed and records made of any hypoglycaemic and hyperglycaemic attacks so that patients may be advised to discontinue fasting if necessary. Patients should also be educated so that they understand:

  • How and when to check their urine for acetone;
  • The warning symptoms of dehydration, hypoglycaemia and hyperglycaemia;
  • The need to break their fast as soon as any complication or harmful condition occurs;
  • The importance of seeking immediate medical help if they have concerns regarding the management of their diabetes;

These educational programmes should commence before the fasting month so that patients are well prepared.

Leedham’s (2000) study of the health promotion needs of people from ethnic minority communities in Wales who have diabetes pointed out difficulties incurred in communication. The study highlighted the problems that arise when English is not a patient’s first language (or even the patient’s second language) and appropriate language support is absent. Focus group participants emphasised that appropriate written information, audiotapes and videos would be useful. (The British Diabetic Association provides both written materials and a video in a variety of South Asian languages).

Focus group participants also felt that group meetings would be a useful addition to the provision of appropriate materials. The participants thought that the mosque would be the most promising venue as mosques are open to all Muslims.

Athar (2002) also indicated the need for an educational programme aimed at people with diabetes during the month of Ramadan. Leaflets should be available from hospitals and GPs’ surgeries well ahead of Ramadan. The information leaflets should be written in different languages, where possible, and should be freely available in order to meet the demands of people who may have problems understanding English.

Patient education is of paramount importance in the management of diabetes as the patient is wholly involved in his or her treatment. Without this education it would be difficult, if not impossible, to manage the patient. Nurses should, therefore, enable patients with diabetes who wish to fast to receive as much information, advice and support as possible.

Pre-fast assessment

Studies indicate that patients with diabetes should be evaluated before the month of Ramadan  to assess their physical well-being, metabolic control and ability to fast (Athar, 2002). Education should include aspects such as home blood glucose monitoring, dietary principles, and any therapeutic adjustments that may be necessary.

Omar and Motala (1997) suggest that some patients with diabetes should be advised not to fast. And Sulimani et al (1998) recommend that caution should be exercised with pregnant women with diabetes who wish to fast. They strongly recommend that these patients should be followed up carefully in diabetic clinics. Health care professionals need to be alert in highlighting patients who come under this category in clinics at the hospitals and at general practices so that they receive the correct advice and monitoring.

Conclusion

Nursing professionals must keep abreast of research and be able to draw on all evidence-based practice that could enhance the quality of care for people with diabetes. Patients with diabetes who wish to fast need the education provided by health care professionals if fasting is to be undertaken safely.

Diabetes can cause problems for Muslims who wish to fast during the holy month of Ramadan. However, through dialogue between health care professionals and patients, together with Ramadan  information packs, it is usually possible to facilitate at least some periods of safe fasting for people with diabetes who wish to observe this annual ritual.

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