DR. FARKHANDA RAHMAN

The word ‘Ramadan’ has stemmed from the Arabic root ‘Ar-Ramad’ meaning intensely heated by sun. Imam Qurtubi notes that “It was named Ramadan because it purges the sins of people with righteous deeds”. For Muslims, Ramadan is the most divinelunar-based month of the year, the timing of which changes with respect to seasons and geographical locations. Eating, drinking, use of oral medications, and smoking from predawn to after sunset are prohibited for a person who fasts during the holy month. Ramadan fasting (one of the five pillars of Islam) is obligatory for every Muslim from puberty and thereafter.

The Holy Qur’an says: “O you who believe! Fasting is prescribed to you as it was prescribed to those before you so that you may attain self-restraint” and “Whoever witnesses the month (of Ramadan) then he/she should fast (2:183). Fasting does not imply overdone hardship on the Muslim individual. The Holy Qur’an precisely immunes the sick from the duty of fasting (2:185), especially if fasting proves harmful to the individual. Patients with diabetes (Type-I, Type-II or gestational) fall under this category.

Diabetes, the chronic metabolic disorder, is an abnormal body condition of reduced or no insulin production (Type-I), improper utilisation of produced insulin (Type-II) or a combination thereof. Fasting may place the victims at high risk of complications if the pattern and amount of their meal and fluid intake is markedly altered. Ramadan is an exalted month wherein the Qur’an was revealed to the Prophet Muhammad (Peace be upon him) as a clear proof of Guidance and as a Criterion of right and wrong (2:185).

Allah’s (SWT) rewards for any good deed are much higher in this holy month than in any other time. This constitutes an intense and passionate desire to do one’s utmost in order to seek the nearness and pleasure of Allah (SWT). It is therefore not surprising that the individuals, who fall in the exempt categories, are loath to take advantage of this concession. The reasons for such conviction to keep the fast aren’t difficult to conclude. The diseased persons either anticipate that they would not be executing their duty as a Muslim, or are unaware of the fact that they have been granted exemption in the event of such a disease.This exemption speaks for more than a simple permission not to fast; the Prophet Mohammad (SAW) said, “God likes his permission to be fulfilled, as he likes his will to be executed”.

Pathophysiology of fasting

In healthy individuals, feeding stimulates insulin secretion which in turn promotes storage of glucose as glycogen in liver and muscles. Contrarily, during fasting, circulating glucose levels tend to fall, contributing to decreased secretion of insulin. Meanwhile, there is a hike in the levels of glucagon and catecholamines, stimulating the breakdown of glycogen while augmenting gluconeogenesis (generation of glucose from non-carbohydrate carbon substrates). Prolonged hours of fasting deplete glycogen reserves leading to increased fatty acid release from adipocytes. Oxidation of these fatty acids generate ketones that can be used as fuel by skeletal and cardiac muscle, liver, kidney, and adipose tissue, thus sparing glucose for continued utilization by brain and erythrocytes. In healthy individuals, these processes and physiological range of glucose concentrations are regulated by a delicate balance between circulating levels of insulin and counterregulatory hormones. However, in diabetic, insulin secretion is disturbed by the underlying pathophysiology andby pharmacological agents designed to improve or supplement insulin secretion.

Risks Associated With Fasting Of Diabetic Persons

Hypoglycemia: Decreased food intake and perturbed hormone levels (glucagon and epinephrine) in diabetic patients are well-known risk factors for the development of hypoglycaemia. The Diabetes Control and Complications Trial (DCCT) summed up a threefold increase in the risk of severe hypoglycemia in patients with an average HbA_1c (A1C) value of 7.0%. 2–4% of mortality in patients with Type-I diabetes has been attributed to hypoglycemia. However, hypoglycemia is an infrequent cause of death in patients with Type-II diabetes.

Hyperglycemia: According to studies, there is a fivefold increase (in patients with Type-II diabetes) and threefold increase (in patients with Type-I diabetes) in the incidence of severe hyperglycemia (requiring hospitalization) during Ramadan. Hyperglycemia may be attributed to excessive reduction in dosages of medications to prevent hypoglycemia and due to intake of heavy large meals at the time of ‘sahoor’ (pre-dawn meal) and ‘iftaar’ (post sunset meal).

Diabetic Ketoacidosis (DKA): It is a serious condition that particularly occurs in fasting patients with Type-I diabetes especially if they are grossly hyperglycaemic before Ramadan. Due to absence of enough insulin in the body to utilize glucose, fatty acid degradation build-up excessive ketones (as fuel) in the blood making it more acidic. This point marks the alarming sign that the diabetes is out of control and the patient needs attention. The risk for DKA is further increased due to excessive reduction of insulin dosages based on the assumption that food intake is reduced during the month.

Dehydration and Thrombosis: Restricted fluid intake during the fast (especially if prolonged), contributes to dehydration especially in excessive perspiration (hot and humid climate, hard physical labour). Furthermore, hyperglycaemia may result in osmotic diuresis leading to hypovolaemia which ends in syncope, falls, injuries, thrombosis, occlusion of blood vessels (e.g., retinal vein) and hypotension. Diabetic patients experience a hypercoagulable state due to hike in clotting factors, decreased endogenous anticoagulants, and impaired fibrinolysis.

Guidelines For Management Of Diabetes During Fasting

Fasting for diabetic patients represents a crucial personal decision made in the light of guidelines for religious exemptions and after ample discussion with the treating physician. Patients who insist on fasting need to be aware of the associated risks and should keenly adhere to the recommendations of their health care professionals to achieve a safer fasting experience. Patients may be at “very high,” “high,” “moderate,” and “low” risk for fasting-related complications depending on the number and extent of their risk factors like; type and duration of diabetes, control on blood glucose levels, HBA1C values, cognitive function, any comorbidity (like renal or optical), prescribed drugs, hours of fasting, type of labour(work). Following guidelines may be followed to manage diabetes during Ramadan fasting:

Individualization: Care of diabetic patients must be highly individualised and the management plan also will differ for each specific person.

Frequent monitoring of glycaemia: Diabetic patients require to monitor their blood glucose levels multiple times daily especially patients with Type-I diabetes and in patients with Type-II diabetes who require insulin.

Nutrition: Healthy and balanced diet (for maintaining a constant body mass) is the need of hour for such patients in Ramadan. Bulk intake of carbohydrate and fat rich foods at sunset meal should be avoided. Foods containing “complex” carbohydrates may be advisable at the predawn meal, while foods with more simple carbohydrates may be more appropriate at the sunset meal. Furthermore, fluid intake should be increased during non-fasting hours and the predawn meal be taken as late as possible before the start of the daily fast. A mobile and web-based application; Ramadan Nutrition Plan (RNP) has been designed to help healthcare professionals (HCPs) individualise medical nutrition therapy (MNT) for people with diabetes. It provides diabetes nutrition plan and education.

Exercise: Every individual should maintain an adequate level of exercise during Ramadan. However, overdone physical activity should be avoided especially during few hours before the sunset meal.  Tarawaih prayer may gloriously be considered as a part of daily workout.

Breaking the fast: While checking daily glucose levels, patients should instantly end their fast if hypoglycemia (blood glucose of <60>

Pre-Ramadan medical assessment: Patients should visit their healthcare person 6-8 weeks before Ramadan, the main aims of which are;

<!--[if !supportLists]-->1.      <!--[endif]-->Provide modified nutritional plan that improves glycaemic control while fasting.

<!--[if !supportLists]-->2.      <!--[endif]-->Provide knowledge about RNP and help obese people to lose weight during Ramadan.

<!--[if !supportLists]-->3.      <!--[endif]-->Adjustment of anti-diabetic medication (dosage and time of administration) according to changes in nutrition of patient during fasting.

<!--[if !supportLists]-->4.      <!--[endif]-->Encourage appropriate physical activity during the Ramadan fasting.

<!--[if !supportLists]-->5.      <!--[endif]-->Provide education to patients about possible acute complication like; warning symptoms of hypoglycaemia, hyperglycaemia, dehydration etc.

<!--[if !supportLists]-->6.      <!--[endif]-->Enforce the significance of blood glucose and body weight monitoring during Ramadan.

Care during pregnancy: During pregnancy there is an increased insulin resistance with a reduction of hepatic insulin extraction. However, postprandial glucose and insulin levels are higher in healthy pregnant women than those who are not pregnant. According to studies, women with pregestational or gestational diabetes should not fast. However, if they insist on fasting, special attention should be given to their care, which may include; near-normal blood glucose and A1C values, counselling about maternal and foetal complications associated with poor glycaemic control, and education focused on self-management skills.

Persons with any type of medical insult should visit their health care professionals before commencing Ramadan fasting (or if it has already started) and even before seeking advice from the religious scholars about fasting queries. Indeed, such individuals should be reminded of the Quranic injunction: “Let not your own hands throw you into destruction”.

(Author is Veterinary Assistant Surgeon, Department of Animal Husbandry, J&K and can be reached at: farkhandarehaman1@gmail.com)