Transcultural awareness is an important topic that is best planned for in advance rather than learning from your mistakes.
How many times have you asked a patient how he or she plans to adjust medications for Ramadan? How many times has a patient asked for assistance in planning for Ramadan? Have you ever told a patient that he or she should not fast for Ramadan due to medical conditions? And did that patient agree to do so, or did he or she proceed with the daily fasting in spite of your advice?
The article in the May/June 2018 issue of Practical Diabetology by Drs. Verma and Hassanein describes the Diabetes and Ramadan Guidelines from the IDF-DAR Alliance that were published in April 2016.
The Diabetes and Ramadan Alliance
The Diabetes and Ramadan (DAR) Alliance was formed in January 2013 following an International Diabetes Federation-Middle East and North Africa Region (IDF-MENA region) meeting. The primary goal of the DAR Alliance is to provide a better understanding of the best strategies to manage diabetes during the month of Ramadan and provide a central location for people with an interest in diabetes and Ramadan to concentrate their efforts, including health-care professionals, patient associations, Muslim societies, and public and private stakeholders.
The IDF-DAR Guidelines are very practical and address the following issues:
- epidemiology of diabetes and Ramadan fasting;
- physiology of Ramadan fasting;
- risk stratification of individuals with diabetes before Ramadan;
- diabetes and Ramadan: a medico-religious perspective;
- pre-Ramadan education;
- Ramadan Nutrition Plan (RNP) for patients with diabetes;
- management of diabetes during Ramadan; and
- identifying and overcoming barriers to guideline implementation.
Before you start asking patients about their plans for diabetes management during Ramadan, review some of the history of Ramadan and familiarize yourself with the timing and duration.
What is Ramadan?
The word “Ramadan” comes from the Arabic root “ramia” or “ar-rama,” which means scorching heat or dryness. Fasting during the month of Ramadan was made obligatory in the second year after the Muslims migrated from Mecca to Medina. The fast starts at sunrise (Suhoor) and ends at sunset (Iftar).
Ramadan, the ninth month of the Islamic calendar, is observed by Muslims worldwide as a month of fasting to commemorate the first revelation of the Quran to Muhammad. This annual observance is one of the Five Pillars of Islam. The month lasts 29 to 30 days, based on the visual sightings of the crescent moon. The end of Ramadan occurs after another crescent new moon has been sighted or the completion of 30 days of fasting if no visual sighting is possible due to weather conditions. The day after Ramadan ends, Shawwal, is the first day of the next lunar month and is called Eid al-Fitr, which is celebrated as a holiday. Fasting is not permitted on this day.
Who should fast?
Fasting is obligatory for adult Muslims, except those who are suffering from an illness, travelling, elderly, pregnant, breast-feeding, diabetic, chronically ill or menstruating. Those unable to fast make up the days missed later. This leads to many patients fasting once or twice a week throughout the year. Although fasting is not obligatory until after puberty, many children fast intermittently during Ramadan as preparation for when they will be adults.
While fasting, Muslims refrain from consuming food, drinking liquids, smoking, sexual activity and any sinful behavior that may negate the reward of fasting, such as false speech (insulting, backbiting, cursing, lying, etc.) and fighting, except in self-defense.
The fast is broken at sunset with the meal called Iftar. According to tradition, Muhammad broke his fast with three dates, so dates are usually the first food consumed. Social gatherings of family and friends are common at Iftar, which may be small or a large community banquet.
Planning for medication management during Ramadan
It is important to discuss all medical conditions with your Muslim patients to ensure they have made plans to adjust the timing of their medications. Fasting patients will not be able to take any medications or injections between sunrise and sunset. It is also important to keep in mind that Iftar, the meal just after sunset, is also a social event, so it will not be a small meal that is eaten quickly. For example, when will a patient take levothyroxine to ensure that it is not within two to four hours of a meal? Or what will be the timing for a blood pressure medication that is usually taken twice daily?
Planning for diabetes management during Ramadan
Although patients with diabetes are excused from fasting, many still plan to fast, so it is imperative to discuss timing and dosing of medication. Although many medications, such as sulfonylureas and rapid-acting insulin, are taken prior to meals, one cannot take a pill or injection until after the fast is broken, when the patient will not likely be in a setting in which he or she can then wait 15 to 30 minutes before starting a meal. Planning the timing of subsequent medication doses can be a challenge because the patient may be eating throughout the night (i.e., “grazing”). Lastly, one has to consider the safety of taking medication just prior to sunrise to avoid developing hypoglycemia while fasting.
Although one always hopes to complete the fast without hypoglycemia, it is necessary to discuss how to manage such events. This starts with determining what symptoms would lead the patient to check blood sugar and reviewing treatment at different glucose levels and when glucagon administration would be recommended. Involvement of family members in this discussion may be crucial. It is also important to remind the patient that if the fast must be broken for hypoglycemia, he or she may want to contact the clinic to discuss the events to devise a plan for the next day so it does not recur.
Initiating a discussion about Ramadan
Opening a dialogue related to religious issues is always sensitive. From experience, most patients are very happy that you are interested enough to raise this topic. It is important to plan to open the discussion well in advance, especially since we typically see patients every three to six months, so we will only see them two to three times between the end of Ramadan one year and the start the next year.
If you have had prior discussions about general Muslim dietary guidelines, the topic of Ramadan is easy to bring up. Otherwise, you will want to think creatively within your clinic structure for strategies to increase awareness of this topic. This may include offering a diabetes education class on different religions throughout the year. You could also put information about the IDF-DAR guidelines on your website and link to the DAR Alliance (www.daralliance.org). The key is to be proactive in letting patients and their families know that your clinic is aware of the significance of Ramadan and that you are open to reviewing plans for management during that time each year.
The IDF-DAR guidelines provide a framework to think about Ramadan and to discuss it with patients and families.
The guidelines stress the importance of individualization and education within a diabetes management plan. Ongoing studies are looking at implementation of these guidelines as well as testing new diabetes medications within this framework.
Access additional resources and practical information to enhance the care and treatment of your diabetes patients.
About our expert: Kathleen Wyne, MD, PhD, FACE, FNLA, Associate Professor, Division of Endocrinology, Diabetes and Metabolism, The Ohio State University, Wexner Medical Center, Columbus, OH