Management of people with diabetes wanting to fast during Ramadan
BMJ 2010; 340 doi: https://doi.org/10.1136/bmj.c3053 (Published 22 June 2010) Cite this as: BMJ 2010;340:c3053
All rapid responses
The requirement to observe a total fast (abstain from all forms of
nourishment including liquids) during daylight hours in the month of
Ramadan (reviewed by Hui and colleagues in the context of diabetes[1])
poses a greater challenge in the management of people who have undergone
bariatric surgery. Bariatric surgery is increasingly performed for the
correction of morbid obesity, particularly in people with co-morbid
conditions such as diabetes [2]. As most bariatric procedures limit the
amount of food or drink that can be consumed in one sitting, patients are
advised to sip fluids frequently through the day. A total fast during long
summer days would put these patients at risk of dehydration. Fasting for
long periods could lead to the desire to eat larger amounts at a faster
pace on breaking the fast. This could result in vomiting, compounding
dehydration and poor nutritional intake. Foods that are frequently eaten
at the sunset meal such as sweets and deep-fried pastries would also put
some patients at risk of dumping syndrome and/or steatorrhoea. The small
stomach volume may also pose a further difficulty with fitting in
nutritional supplements and medications around meal times.
Research in this area is virtually non-existent. Based on clinical
experience we recommend that:
• Patients should avoid total fasts in the first 12 – 18 months after
bariatric surgery when new eating and drinking habits are being
established
• Beyond this period the risk of post prandial vomiting is reduced
and patients who are otherwise in good health may observe religious fasts
if fluids can be taken through the day (e.g. fasting in the season of
Lent)
• Patients should be advised to base their meals on complex
carbohydrates and high quality proteins to optimise their nutritional
status
• Patients who have had malabsorptive procedures such as gastric
bypass should be advised of the importance of continuing with their
nutrient supplements such as iron, calcium and vitamin D, and
multivitamins.
Fiona Chan, specialist weight management dietitian
Chris Slater, specialist bariatric dietitian
Akheel A Syed, consultant physician
Department of Obesity Medicine, Salford Royal NHS Foundation Trust & University Teaching
Hospital, Salford, Greater Manchester M6 8HD
References
1. Hui E, Bravis V, Hassanein M, Hanif W, Malik R, Chowdhury TA, et
al. Management of people with diabetes wanting to fast during Ramadan. BMJ
2010;340:c3053.
2. Leff DR, Heath D. Surgery for obesity in adulthood. BMJ
2009;339:b3402.
Competing interests:
None declared
Competing interests: No competing interests
E Hui et al have reviewed and summarised management of Muslim
patients during Ramadan (1).
The advice for diet, exercise, home blood glucose monitoring and
recognising and managing complications are generic to all the patients
suffering from diabetes mellitus however, they need to be strictly adhered
to during fasting.
There are other issues to be addressed with respect to Ramadan and
fasting if one suffers from type 1 diabetes mellitus, type 2 diabetes or
gestational diabetes.
The zeal to fast is so great at times that the person does not pay
attention to the instructions by a health professional about the risks of
hyperglycaemia, hypoglycaemia or dehydration. Other times a person with
diabetes does not wish to fast but goes through with it because he or she
does not want to alienate themselves from the rest of the Muslim
community. Therefore, it is very important that the Muslim religious
leaders clearly instruct the followers especially the high risk patients,
young adults, pregnant ladies and elderly people that they are exempt and
will not suffer from any consequences if they do not fast.
Authors state that patients with diabetes who want to fast need an
assessment before Ramadan and education to increase their awareness of the
risks of fasting. The education of the context of religious fasting should
be brought home to them as well. The idea of fasting is to be able to
relate to poor people, exercise self control and discipline and eat less.
What happens in real life is that for fear of hypoglycaemia, patients with
diabetes overindulge in the morning. They overeat in the evening as well
because they are very hungry. It is not only a matter of overeating but
also the wrong foods ie fried fatty kababs, samosas and pakoras. So in
fact they end with more total calories/ day as compared to when they were
not fasting. The diabetes control is going to be poor irrespective of
their control before they started to fast. This highlights correct
religious education and getting rid of the myths.
The summary states that National Institute for Health and Clinical
Excellence emphasise the importance of individualising care on the basis
of patients’ social, cultural, and religious needs. However, patients also
should also take some responsibility of managing themselves according to
their condition, diabetes control and risk. This highlights mutual
agreement or contract for care.
(1)Management of people with diabetes wanting to fast during Ramadan
E Hui, , V Bravis, , M Hassanein, , W Hanif, , R Malik, , T A Chowdhury, ,
M Suliman, , D Devendra, 22 June 2010, doi:10.1136/bmj.c3053
Competing interests:
None declared
Competing interests: No competing interests
Re: Management of people with diabetes wanting to fast during Ramadan
Dear Editor
Re: Management of people with diabetes wanting to fast during Ramadan
Almoutaz Alkhier Ahmed 1, Emad Alsharief 2, Ali Alsharief 3
We read with great interest your paper entitled ”Management of people with
diabetes wanting to fast during Ramadan“ published on BMJ 26 June 2010,
and we have the following comments:
Comment 1:
Box 1: Risk stratification in patients with type 1 or type 2.
We noticed that you consider those with severe and recurrent episodes of
hypoglycemia and unawareness as having high risk.
In our opinion this needs to be reformated to those with unexplained severe or
recurrent episodes of hypoglycemia and unawareness. We think those who know
the reason(s) for their episodes are usually patients with good control
and for certain known causes they developed episodes of hypoglycemia such
as those with good glycemic control on either oral or insulin therapy and
they missed their mail or doing vigorous exercises without taking extra
meals, such patients could be labeled as under moderate or low risk as they
only need education and awareness about the cause. Those who have
unexplained causes for severe or recurrent episodes of hypoglycemia or
unawareness are those who are at high risk because episodes cannot be
predicted by the patient or their health providers; these patients were
known previously as patients with brittle diabetes.
Comment 2:
In box 2: Four key areas in Ramadan focused on education.
The 2nd key area:
We notice that you stated that in case of subjective symptoms of
hypoglycemia , you suggested confirmation of hypoglycemia to break
fasting.
We think the issue of fasting is based on the self capability to do it, so if
the patient has symptoms suggestive of hypoglycemia and he/she feels that
he/she could not continue the fasting no matter what will be the result of
their blood glucose and they can break their fasting. In practice we face
this with patients who are accustomed to high blood glucose and with fasting
their blood glucose will go down and they will start to feel symptoms of
hypoglycemia although their meter gives readings that are not diagnostic of
hypoglycemia.
The 4th key area:
As we talk about Ramadan and management of diabetes during it, patients
need to know about acute complications. We think the title of the fourth
key area should be “Recognizing and managing acute complications”,
although this does not mean that educators will ignore the chronic
complications but it is important in education to tell the patient what is
critical to know fabout specific topic which is how to fast during Ramadan
safely.
Comment 3:
Although the paper discussed and suggested recommendations for most
management regimens, it missed discussing the issue of long acting
insulin therapy and how to deal with it in Ramadan and also missed to discuss
the issue of insulin pump therapy in Ramadan.
Comment 4:
We think that the algorithm posted on page 1410 is an interesting algorithm
and summarizes perfectly the paper.
*Crosspondance to:
1 Dr.Almoutaz Alkhier Ahmed
Pg Dip in Diabetes (Cardiff University- UK)
Gurayat Diabetes Center
Saudi Arabia
e.mail:khier2@yahoo.com
2 Dr.Emad Alsharief
Counsultant family medicine
National Guard Health Affairs-Jeddah
Jeddah
Saudi Arabia
3 Dr.Ali Elsharief
Counsultant family medicine
National Guard Health Affairs-Jeddah
Jeddah
Saudi Arabia
Competing interests:
None declared
Competing interests: No competing interests