Practical Management of Diabetes during Ramadan Fast

Introduction Fasting in Ramadan is obligatory for all healthy Muslim adults. No food or drink may be consumed between dawn and sunset [1]. Strictly speaking, the fast of Ramadan is a period of “intermittent fasting” or daily cycles of “alternating” fasting and feeding periods. The periods of the fasting and feeding vary by the geographical locations and by time of the year. During the month of Ramadan, there are two main meals in most Moslem communities. These are commonly referred to by their Arabic origin, namely the “Iftar” (i.e. break of fast immediately after sunset) and “Sohur or Suhoor” (i.e. pre-dawn meal). As the Islamic calendar year is lunar, Ramadan (the ninth month) therefore starts approximately 10 days earlier each year on the Gregorian calendar. This year, 2007, Ramadan is likely to start between 12 and 14 September. Certain groups are exempt from fasting temporarily or permanently including the sick, the elderly, the travellers and the expecting and nursing mothers [1]. However, many of those who are exempt may wish to observe the fast [2]. It is the responsibility of the medical professional to empower patients to make an informed choice and, if possible, an evidence-based decision. There are several studies on the changes observed in clinical, body composition, and biochemical parameters during the fasting month of Ramadan in healthy subjects and in various medical conditions. The EPIDIAR Study was the largest study reported involving 1,070 patients with type 1 diabetes and 11,173 patients with type 2 diabetes [2]. Less than 50% of the whole population changed their treatment and hypoglycaemia was the only observed event. There are also a few studies which evaluated specific management modalities in those patients with diabetes who observed the fast [3-5]. These have been adequately summarised and discussed in previous review articles, expert opinion statements, and conferences proceedings over the last two decades [6-13]. A further detailed summary and critical appraisal of these studies is outside the scope of this article. Our aim here is to present a practical approach to the assessment of diabetic patients before Ramadan and provide a guide on how to adjust the life style and medical management appropriately should the patient wish to observe the fast having deemed it to be reasonably safe. Management of people with diabetes during Ramadan: Organizational Issues The management of diabetes during Ramadan fasting should be considered well in advance of the holy month. Diabetes care departments should have comprehensive strategy meetings a few months before Ramadan. Many patients would have developed their own opinions and established their practices of amending their diabetes care management plans from previous personal experience. Patients attending diabetic clinics should be encouraged to seek advice before considering fasting the month of Ramadan [13]. However, poor knowledge about Ramadan and fasting and its management have been described among some health care professionals [14]. For patients, leaflet and booklets containing information and advice about Ramadan fasting for people with diabetes ought to be available in the waiting areas of diabetic clinics at least 3 months before the month starts (Figure 1). Special classes may need to be considered to enhance selfmanagement during this month [15]. Media presenters of health programmes and healthcare journalists should prepare such educational programmes in advance of the month of Ramadan. Expert doctors should take the time to give interviews preferably jointly with Imams to offer clear and authoritative views and respond to all commonly asked questions. In the clinical settings, doctors should have a clear understanding of the religious ruling on fasting to give their advice with confidence.