Rapid Responses to:
|
|
Rapid Responses: Rapid Responses published:
-
![[Read Rapid Response]](/icons/misc/sectionDOWN.gif)
Ramadan a good time to help smokers quit
- Kawaldip Sehmi (1 October 2004)
-
Drug intake during Ramadan month affects dermatological ailments
- Dr. Vijay P. Zawar (1 October 2004)
-
Physicians should put health in perspective during Ramadan
- Rajan T.D (4 October 2004)
-
Fasting in ramadan is not the only consideration when prescribing for muslim patients
- Geraldine A B Mynors (6 October 2004)
-
Ramadan Fasting in Europe
- Norbert Klöcker MD PhD (10 October 2004)
-
More awareness needed among ethnic minorities and health service
- Qaim Zaidi (11 October 2004)
-
Eye drops during Ramadan
- Trisha Greenhalgh (14 October 2004)
-
Drug intake during Ramadan
- Tahseen A. Chowdhury, David B. Peterson (14 October 2004)
-
Forewarning before fasting
- Shahid A Khan, Maham Khan (24 October 2004)
-
Re: Physicians should put health in perspective during Ramadan
- Jeffrey Cohen (29 September 2005)
|
|
|||
|
Kawaldip Sehmi, Director Health Ineqaulities QUIT 211 Old Street London EC1V 9NR
Send response to journal:
|
We believe that the BMJ has published a landmark paper. Every year during the month of Ramadan, QUIT runs a major public health campaign targeting some 1.6 million British Muslims on smoking and heart disease through the ethnic media and the Imams (priests) of some 300 mosques. In our experience, unpublished evaluation reports, this is the best time to carry out a healthy lifestyle based campaign amongst the Muslim communities in Britain as the civic mood and personal attitude of many Muslims communities is ripe for behavioural change and health improvement. Muslim Health Network, a voluntary organisation (www.muslimhealthnetwork.org), has addressed the issue of patients on medication by issuing the following caveat: Through Koranic Verse, Hadiths (Sunna)and notable commentary made by many Fiqhs (schools of law), the following are exempt from the obligation of fasting: 1) Those who are ill-extended by modern scholars to include those on medication and with mental health problems 2) Breast feeding mothers 3) People on a journey Further, by using the portion of the verse 185 Surah 2 (Al Baqarah): "Allah intends every facility for you; He does not want to put you in difficulties.", we have supported patients in refraining from harming themselves by adopting harsh and continuous fasting regimes. We believe that it is important to understand and support the patient's spiritual and physiological needs by advising and counselling them in a culturally sensitive manner. This paper goes a long way to establish the evidence base that we need to do this. Competing interests: None declared |
|||
|
|
|||
|
Dr. Vijay P. Zawar, Lecturer NDMVPS Medical College, Nashik-422003
Send response to journal:
|
An article by Aadil et al published in the recent issue of BMJ is quite interesting and raises very practical issues. I have faced similar problems in my practice during the months of Ramadan in last several years while treating various skin problems. Two conditions are worth mentioning where I have experienced a serious impact in the patients' treatment. One, while treating Herpes Zoster, a common drug used is Acyclovir which needs to be given every five hours for atleast 5-7 days. The schedule of this drug is highly unacceptable to most of the muslim patients of mine. The alternative drug only recently available in the Indian markets if Famciclovir, which needs to be given three times a day. This drug also does not permit those patients fasting for Ramadan and do not take anything by mouth from dawn to dusk. Consequently,there is delayed recovery from the illness. Apart from the morbidity of the disease,inadequate control of the neural inflammation might subject especially the elderly population to a problem of post-herpetic neuralgia. Not only that, inadequately spaced doses of the antiviral drug may run a significant risk of drug resistance considering bioavailability of acyclovir. Second, while inducing remission in the cases of full-blown Pemphigus Vulgaris, not an infrequent disease in the Asians. Here, we need to administer the high doses of corticosteroids to suppress the immunologically induced disease more frequently than could be given avoiding the dusk-dawn pattern of the intake during the Ramadan months. Thus it often leads to an inadequate control of the disease leading to increased disease morbidity and may possibly invite complications of disseminated infections through the denuded areas of skin lesions which are good portal for bacterial sepsis. Those patients who additionally have one or the other systemic illness like hypertension, diabetes and acid peptic disease, such dosages of drugs conforming the pattern of administration during the Ramadan month may be additional burden on the patients for the fear of gastric irritation due to polypharmacy for their original systemic disease plus the skin illness. Competing interests: None declared |
|||
|
|
|||
|
Rajan T.D, Consultant Skin & Sex Transm Diseases, Andheri 0091-22-56982747 Andheri 0091-22-28329825
Send response to journal:
|
In India, a large chunk of Muslim population observe fasting during Ramadan. With the desire to appease their faith most people observe dusk to dawn fast even if they are not in sound health. Physicians often try to tailor the prescription to suit the convenience of the patient to help them observe the fast which occasionally could be at the cost of optimum control of the illness. While any effort to make the treatment pattern to the patient's convenience is appropriate, it is imperative that the physician puts the patient's illness as well as his religious feelings in the right perspective. No religion insists on people who are ill to observe any type of dietary restriction. Damaging one's own health in the name of religion is damaging to the well-being of the family and consequently to society. Therefore the physician should explain in clear terms the need to take meals and medicines at proper times in the best interest of the patient. Competing interests: None declared |
|||
|
|
|||
|
Geraldine A B Mynors, Head of Projects, Medicines Partnership 1 Lambeth High Street, London SE1 7JN
Send response to journal:
|
This review highlights the importance of cultural understanding and sensitivity when agreeing treatment plans with muslim patients, and of not making assumptions about how muslim patients will or will not act in relation to their medicines based on their religious conviction. However, the issue of fasting during Ramadan is not the only one which may have a bearing on culturally sensitive treatment for muslim patients. Disregard for religious beliefs in relation to ingredients can have a further important bearing on compliance with treatment, as reflected, for example, in a UK study which found that 58% of British Muslim patients indicated that they would stop taking prescribed medications found to contain religiously prohibited ingredients (Bashir A, Asif F, Lacey F, Marriorr J, Wilson K. Concordance in Muslim patients in primary care Int J Pharm Pract 2001:9:R78). Recent work carried out by a UK based expert group on this topic has resulted in the publication in April 2004 of a BNF-sized booklet for health professionals on drugs of porcine origin and their clinical alternatives. The booklet not only provides a directory of drugs of porcine origin and their alternatives, but also provides guidance on the religious and cultural aspects of porcine derived products and explains why and how patients of all faiths should be involved in decisions about their medicines if the pitfalls of cultural misunderstanding are to be avoided. It is available at http://www.medicines-partnership.org/our- publications/drugs-of-porcine-origin Competing interests: None declared |
|||
|
|
|||
|
Norbert Klöcker MD PhD, Medical Consultant D-65510 Instein
Send response to journal:
|
EDITOR – Aadil et al approach some interesting ad important problems which affect the healthcare community when patient adhering to Islam are treated. The BMJ has traditionally given a lot of attention to the subject and the problem is of increasing importance also in non-Islamic coutries, e.g. Great Brittain with its large Pakistany/Indian population, France and the Benelux countries with their rapidly increasing number of immigrants from Northern Afrika and Germany with at least 3 millions of Turkish people. Besides cultural differences, missing knowledge about rules for exeptions from fasting often the simple lack in the langauges of their host-countries make cummunication between European physicians and Muslims difficult. Furthermore, many Muslims understand illnesses differernt from Europeans. Even if the Koran allows exemptions from fastig for patients with acute or chronic illnesses, pregnancy, being on travel, etc it is rather difficult to have access to food during daylight in an islamic environment and the socio-cultural pressure to fast is increasing with a more orthodox way of living. Many patients insist on fasting as it is one of the main principles of Islam. The authors state, that Ramadan can occur during all seasons, for the comming years it will be 15.Oct – 13 Nov 2004, 05 Oct – 02. Nov 2005, 24. Sept – 22 Oct 2006 and 13 Sept – 11 Oct.2007. As is clear vom these dates, Radadan will be held each year two weeks earlier, for Europe in a few years during summertime. This means, that the hours for food intake will bekome shorter, the time of fasting will become longer and the climate will be hotter. This is of great medical importance regarding dehydration and it will affect in particular the elderly and females with a often low intake of fluids, workers in the open, children and people with intensive sport activities. It is known, that creatinine values rise significantly during Ramadan1. Another important aspect is the change in dietary patterns during Ramadan. Unlike the fasting period of Christians before Eastern, where food often is reduced in quantity and quality, and sweets and alcohol are avoided, the food in the Muslim population is often better than outside Ramadan, as it is a traditional habit, that the more wealthy relatives invite the not so wealthy and the rich feed the poor. This results in an increase of body weigt and BMI2. Aadil and al discuss the need of larger and prospective studies, in particular with respect to chronic deseases. Suprisingly, the have forgotten to mention the lagest study on this topic3 and the consequences for treatment during Ramadan. This prospective, randomised multicentre study in 591 Moroccan diabetics over a period of three months could show that the reversal of morning and evening doses, with the addition of any midday dose to that taken in the evening is effective and the patients diabetes remained as well controlled as that of patients who did not fast. When we have data and know how it should be used, especially in a review. 1 SH Chea, SL Ch’Ng, R Husain, MT Duncan. Effects of fasting during Ramadan on urinary excretion in Malaysian Muslims. Br J Nutr 1990; 63: 329 -37 2 N Klöcker , J Belkhadir, H El Ghomari, A Mikou, M Naciri, M Sabri. Ramadan and the influence of Body weight on metabolic parameters in fasting NIDDM patient. Proceedings of the 1° International Congress on Health and Ramadan, Casablanca 1994: 186-8 3 J Belkhadir J, H El Ghomari, N Klöcker, A Mikou, M Naciri, M Sabri. Muslims with non-insulin dependent diabetes fasting during Ramadan: treatment with glibenclamide. MBJ 1993, 307: 292-5 Competing interests: None declared |
|||
|
|
|||
|
Qaim Zaidi, British Heart Foundation Ethnic Strategy Co-ordinator British Heart Foundation, 14 Fitzhardinge Street, London SW17 6AP
Send response to journal:
|
Aadil et al observe that patients arbitrarily change intake times and dosing for drugs without taking medical advice. Furthermore some people with chronic diseases fast even though there is no religious imperative on those who are sick to do so. The British Heart Foundation (BHF) recognises that many Muslims who are fasting are not seeking advice from their physicians and may endanger their health. For this reason the BHF has started various programmes to address this issue. In partnership with the Bradford University School of Pharmacy we have been training mosque imams (priests) in prevention and management of diabetes and coronary heart disease (CHD). Imams have the potential to play a major role in disseminating information as they hold a unique position of credibility in their local communities. They are often approached for advice on personal and social issues. During the month of Ramadan many more Muslims than usual visit mosques for prayers and breaking their fasts and the potential of imams to convey appropriate health messages is substantially increased. Such messages can be tailored in terms of religious imperatives to look after one’s health and the BHF’s initiatives have sought to highlight these. Many Muslims use the month of Ramadan to make healthy changes to their lifestyles. This is used by the BHF and partner organisations as an opportunity to use relevant media in order to, for example, launch quit smoking campaigns and to raise awareness of heart disease, its prevention and management. Many first generation Asians only access ethnic language media and we use them to hold discussion programmes and we invite scholars and physicians to discuss these issues. We hope that with these programmes we will be able to make a difference. Of course the dialogue between patients and health service personnel will be more meaningful if the latter are aware of the beliefs of their patients. We also feel that there is a need to train physicians in the cultural norms of minority communities, of whom there are a substantial number in the UK (for example there are over 1.5 million Muslims). In conclusion, it is clear there is a need for better awareness on both sides – a need the BHF is striving to answer. Competing interests: None declared |
|||
|
|
|||
|
Trisha Greenhalgh, Professor of Primary Care University College London
Send response to journal:
|
The people interviewed in this study did not consider that inserting eye drops counted as breaking the fast. During a training course I ran for bilingual health advocates in East London, I heard a story of a patient with glaucoma who discontinued their eye drops during the hours of daylight. The patient was said to have gone blind. Ironically, the drops were available as a slow-release formulation. As in any religion, there may be wide diversity in the individual interpretation of prescribed rites and rituals. Whilst the patient in my story may have been unusual, it surely does no harm to ask a person if they PLAN to discontinue their 'topical' medication during a prolonged fast, and be prepared to suggest alternatives if they do. Competing interests: None declared |
|||
|
|
|||
|
Tahseen A. Chowdhury, Consultant in Diabetes Department of Diabetes and Metabolism, The Royal London Hospital, Whitechapel, London E1 1BB, David B. Peterson
Send response to journal:
|
Dr Aadil and colleagues very helpful review of the changes in drug intake during Ramadan serves as a useful reminder to all health care professionals looking after Muslim people during this time 1. An interesting omission was the use of medication for both type 1 and type 2 diabetes during Ramadan. As a service looking after the largest concentration of Muslim people in the UK, we are very much aware of the major impact Ramadan can have on the management of diabetes, and have developed a number of services aimed at supporting patients with diabetes during Ramadan, including pre-Ramadan classes on diabetes management over Ramadan, and a help-line for patients during Ramadan 2. It should be emphasised to patients with diabetes that they are exempt from fasting by almost all Muslim authorities. Nevertheless, in our experience, most Muslim people with diabetes feel the spiritual need or social pressure to fast, and surveys in our own department have shown that many will ignore medical advice against fasting (unpublished data). Changes to oral hypoglycaemic therapy during Ramadan are frequently necessary. Whilst patients on metformin can frequently just omit their lunchtime dose, care needs to be taken with sulphonylureas (SU) during fasting. Avoidance of long acting SUs such as glibenclamide is necessary. The dose of shorter acting SUs such as gliclazide, may have to be modified during Ramadan, and we generally suggest halving the dose with the meal at dawn, but continuing normal dose in the evening. Well controlled patients on twice daily gliclazide may benefit from conversion to rapid acting insulin secretagogues such as repaglinide or nateglinide. Patients on insulin therapy should be strongly discouraged from fasting, but if insistent, they should be offered support. Patients on twice daily mixed insulin and reasonable glycaemic control should reduce the morning dose by half, and continue the normal dose in the evening. Patients on basal bolus regimens may be able to get away with just missing lunchtime insulin. Of great importance is the advice to check blood tests frequently during fasting. Some patients are under the misconception that blood testing breaks the fast, and this myth should be strongly dispelled. Management of diabetes over Ramadan is a challenge for patients and health care professionals. With careful support and advice, along with judicious changes in drug therapy, successful outcomes can be achieved. Dr Tahseen A Chowdhury Consultant in Diabetes Dr David B Peterson Consultant in Diabetes Department of Diabetes and Metabolism The Royal London Hospital Whitechapel London E1 1BB E-mail:Tahseen.Chowdhury@bartsandthelondon.nhs.uk References 1. Aadil N, Houti IE, Moussamih S. Drug intake during Ramadan. BMJ 2004; 329: 778-82 2. Chowdhury TA, Hussain HA, Hayes M. Models of good practice. An education class on diabetes self-management during Ramadan. Practical Diabetes 2003; 20: 306-7 Competing interests: None declared |
|||
|
|
|||
|
Shahid A Khan, Consultant Physician Lister Hospital, Stevenage. Herts. SG1 4AB, Maham Khan
Send response to journal:
|
Dr Aadil and colleagues have provided a timely review of problems faced by both Muslim patients and their doctors during the month of fasting. However one gets the impression that most Muslim patients would observe fasting irrespective of their illness. Islam forbids any act that would be harmful to an individual. A person who deliberately puts his health at risk by fasting against the advice of his physician, contradicts this basic principle of Islam. Hence fasting against doctor’s advice would contravene the basic principle of fasting. For those who are unable to fast, Islam not only provides exemptions but offers other alternatives. Islamic scholars and Imams have a responsibility to educate patients and communities. Doctors and nurses have a duty to point out the above facts where their patient’s health may be at risk by fasting. Only in circumstances where the patient intends to fast, despite clear warning from their doctor, should advice be given to tailor therapy. Rearranging the patient’s medications for fasting before a formal warning, will give the wrong message and may encourage some patients to fast who should not fast otherwise. Competing interests: None declared |
|||
|
|
|||
|
Jeffrey Cohen, Visiting Senior Research Fellow, School of Public Health and Community Medicine Faculty of Medicine, University of New South Wales NSW 2052 Australia
Send response to journal:
|
when the author wrote "most people observe dusk to dawn fast" I have to assume this was a typographical error since it is the exact opposite that the fast is from dawn to dusk. Competing interests: None declared |
|||