37 years
Sir,kindly tel about fasting in the month of ramadan by a diabetes type 1 patient(insulin dependent)
Jul 4, 2014
Ramadan is a lunar-based month, and its duration varies between 29 and 30 days.
Depending on the geographical location and season, the duration of the daily fast may range from a few to more than 20 h. Muslims who fast during Ramadan must abstain from eating, drinking, use of oral medications, and smoking from predawn to after sunset; however, there are no restrictions on food or fluid intake between sunset and dawn. Most people consume two meals per day during this month, one after sunset, referred to in Arabic as Iftar (breaking of the fast meal), and the other before dawn, referred to as Suhur (predawn).
Fasting is not meant to create excessive hardship on the Muslim individual. The Koran specifically exempts the sick from the duty of fasting (Holy Koran, Al-Bakarah, 183–185), especially if fasting might lead to harmful consequences for the individual.Patients with diabetes fall under this category because their chronic metabolic disorder may place them at high risk for various complications if the pattern and amount of their meal and fluid intake is markedly altered. This exemption represents more than a simple permission not to fast;
IN GENERAL, patients with type 1 diabetes, especially if “brittle” or poorly controlled, are at very high risk of developing severe complications and should be strongly advised to not fast during Ramadan. In addition, patients who are unwilling or unable to monitor their blood glucose levels multiple times daily are at high risk and should be advised to not fast.
Nevertheless, many patients with diabetes insist on fasting during Ramadan, thereby creating a medical challenge for themselves and their physicians.It is worth reemphasizing that fasting for patients with diabetes represents an important personal decision that should be made in light of guidelines for religious exemptions and after careful consideration of the associated risks following ample discussion with the treating physician. Most often, the recommendation will be to not undertake fasting. However, patients who insist on fasting need to be aware of the associated risks and be ready to adhere to the recommendations of their health care providers to achieve a safer fasting experience. Patients may be at higher or lower risk for fasting-related complications depending on the number and extent of their risk factors.
Some of the major potential complications associated with fasting in patients with diabetes are:
1-Hypoglycemia
Decreased food intake is a well-known risk factor for the development of hypoglycemia.
2-Diabetic ketoacidosis
Patients with diabetes, especially those with type 1 diabetes, who fast during Ramadan are at increased risk for development of diabetic ketoacidosis, particularly if they are grossly hyperglycemic before Ramadan (4). In addition, the risk for diabetic ketoacidosis may be further increased due to excessive reduction of insulin dosages based on the assumption that food intake is reduced during the month.
3-Dehydration and thrombosis
Limitation of fluid intake during the fast, especially if prolonged, is a cause of dehydration. The dehydration may become severe in hot and humid climates and among individuals who perform hard physical labor, all conditions that result in excessive perspiration.Orthostatic hypotension may develop, especially in patients with preexisting autonomic neuropathy. Syncope, falls, injuries, and bone fractures may result from hypovolemia and the associated hypotension. In addition, contraction of the intravascular space can contribute to a hypercoagulable state.
I. GENERAL CONSIDERATION:
Several important issues deserve special attention.
>Individualization.
Perhaps the most crucial issue is the realization that care must be highly individualized and that the management plan will differ for each specific patient.
>Frequent monitoring of glycemia.
It is essential that patients have the means to monitor their blood glucose levels multiple times daily. This is especially critical in patients with type 1 diabetes and in patients with type 2 diabetes who require insulin.
>Nutrition
The diet during Ramadan should not differ significantly from a healthy and balanced diet. It should aim at maintaining a constant body mass.
Ingesting large amounts of foods rich in carbohydrate and fat, especially at the sunset meal, should be avoided. Because of the delay in digestion and absorption whereas,
Ingestion of foods containing “complex” carbohydrates may be advisable at the predawn meal
Foods with more simple carbohydrates may be more appropriate at the sunset meal. It is also recommended that fluid intake be increased during nonfasting hours and that the predawn meal be taken as late as possible before the start of the daily fast.
>Exercise
Normal levels of physical activity may be maintained. However, excessive physical activity may lead to higher risk of hypoglycemia and should be avoided
>Breaking the fast
All patients should understand that they must always and immediately end their fast if hypoglycemia (blood glucose of <60 mg/dl [3.3 mmol/l]) occurs, since there is no guarantee that their blood glucose will not drop further if they wait or delay treatment. The fast should also be broken if blood glucose reaches <70 mg/dl (3.9 mmol/l) in the first few hours after the start of the fast, especially if insulin, sulfonylurea drugs, or meglitinide are taken at predawn. Finally, the fast should be broken if blood glucose exceeds 300 mg/dl (16.7 mmol/l). Patients should avoid fasting on “sick days.”
>Pre-Ramadan medical assessment and educational counseling
All patients with diabetes who wish to fast during Ramadan should undergo the necessary preparations to undertake the fast as safely as possible. These include medical assessment and educational counseling.
-Medical assessment
This assessment should take place within 1–2 months before Ramadan. Specific attention should be devoted to the overall well-being of the patient and to the control of their glycemia, blood pressure, and lipids. Appropriate blood studies should be ordered and evaluated. Specific medical advice must be provided to each individual patient concerning the potential risks they are accepting in deciding to fast, even if they fast against medical advice. During this assessment, necessary changes in their diet or medication regimen should be made so that the patient initiates fasting while being on a stable and effective program.
-Educational counseling
It is essential that the patients and family receive the necessary education concerning self-care, including signs and symptoms of hyper-and hypoglycemia, blood glucose monitoring, meal planning, physical activity, medication administration, and management of acute complications. Adequate nutrition and hydration should be emphasized, in addition to ensuring preparedness to treat hypoglycemia promptly should it occur, even if it is mild .
>Management of patients with type 1 diabetes
Close monitoring and frequent insulin dose adjustments in this setting are essential to achieve optimal glycemic control and avoid hypo- or hyperglycemia in patients with type 1 diabetes.
It is unlikely that one injection of intermediate- or long-acting insulin administered before the evening meal would provide adequate insulin coverage for 24 h.The doctor following the diabetic patient is the one able to plan the insulin injections and timings depending on the blood sugar control .
CONCLUSION:
Fasting during Ramadan for patients with diabetes carries a risk of an assortment of complications. In general, patients with type 1 diabetes should be strongly advised to not fast. Patients with type 1 diabetes who have a history of recurrent hypoglycemia or hypoglycemia unawareness or who are poorly controlled are at very high risk for developing severe hypoglycemia.On the other hand, an excessive reduction in the insulin dosage in these patients (to prevent hypoglycemia) may place them at risk for hyperglycemia and diabetic ketoacidosis.A patient’s decision to fast should be made after ample discussion with his or her physician concerning the risks involved. Patients who insist on fasting should undergo pre-Ramadan assessment and receive appropriate education and instructions related to physical activity, meal planning, glucose monitoring, and dosage and timing of medications. The management plan must be highly individualized. Close follow-up is essential to reduce the risk for development of complications.
Depending on the geographical location and season, the duration of the daily fast may range from a few to more than 20 h. Muslims who fast during Ramadan must abstain from eating, drinking, use of oral medications, and smoking from predawn to after sunset; however, there are no restrictions on food or fluid intake between sunset and dawn. Most people consume two meals per day during this month, one after sunset, referred to in Arabic as Iftar (breaking of the fast meal), and the other before dawn, referred to as Suhur (predawn).
Fasting is not meant to create excessive hardship on the Muslim individual. The Koran specifically exempts the sick from the duty of fasting (Holy Koran, Al-Bakarah, 183–185), especially if fasting might lead to harmful consequences for the individual.Patients with diabetes fall under this category because their chronic metabolic disorder may place them at high risk for various complications if the pattern and amount of their meal and fluid intake is markedly altered. This exemption represents more than a simple permission not to fast;
IN GENERAL, patients with type 1 diabetes, especially if “brittle” or poorly controlled, are at very high risk of developing severe complications and should be strongly advised to not fast during Ramadan. In addition, patients who are unwilling or unable to monitor their blood glucose levels multiple times daily are at high risk and should be advised to not fast.
Nevertheless, many patients with diabetes insist on fasting during Ramadan, thereby creating a medical challenge for themselves and their physicians.It is worth reemphasizing that fasting for patients with diabetes represents an important personal decision that should be made in light of guidelines for religious exemptions and after careful consideration of the associated risks following ample discussion with the treating physician. Most often, the recommendation will be to not undertake fasting. However, patients who insist on fasting need to be aware of the associated risks and be ready to adhere to the recommendations of their health care providers to achieve a safer fasting experience. Patients may be at higher or lower risk for fasting-related complications depending on the number and extent of their risk factors.
Some of the major potential complications associated with fasting in patients with diabetes are:
1-Hypoglycemia
Decreased food intake is a well-known risk factor for the development of hypoglycemia.
2-Diabetic ketoacidosis
Patients with diabetes, especially those with type 1 diabetes, who fast during Ramadan are at increased risk for development of diabetic ketoacidosis, particularly if they are grossly hyperglycemic before Ramadan (4). In addition, the risk for diabetic ketoacidosis may be further increased due to excessive reduction of insulin dosages based on the assumption that food intake is reduced during the month.
3-Dehydration and thrombosis
Limitation of fluid intake during the fast, especially if prolonged, is a cause of dehydration. The dehydration may become severe in hot and humid climates and among individuals who perform hard physical labor, all conditions that result in excessive perspiration.Orthostatic hypotension may develop, especially in patients with preexisting autonomic neuropathy. Syncope, falls, injuries, and bone fractures may result from hypovolemia and the associated hypotension. In addition, contraction of the intravascular space can contribute to a hypercoagulable state.
I. GENERAL CONSIDERATION:
Several important issues deserve special attention.
>Individualization.
Perhaps the most crucial issue is the realization that care must be highly individualized and that the management plan will differ for each specific patient.
>Frequent monitoring of glycemia.
It is essential that patients have the means to monitor their blood glucose levels multiple times daily. This is especially critical in patients with type 1 diabetes and in patients with type 2 diabetes who require insulin.
>Nutrition
The diet during Ramadan should not differ significantly from a healthy and balanced diet. It should aim at maintaining a constant body mass.
Ingesting large amounts of foods rich in carbohydrate and fat, especially at the sunset meal, should be avoided. Because of the delay in digestion and absorption whereas,
Ingestion of foods containing “complex” carbohydrates may be advisable at the predawn meal
Foods with more simple carbohydrates may be more appropriate at the sunset meal. It is also recommended that fluid intake be increased during nonfasting hours and that the predawn meal be taken as late as possible before the start of the daily fast.
>Exercise
Normal levels of physical activity may be maintained. However, excessive physical activity may lead to higher risk of hypoglycemia and should be avoided
>Breaking the fast
All patients should understand that they must always and immediately end their fast if hypoglycemia (blood glucose of <60 mg/dl [3.3 mmol/l]) occurs, since there is no guarantee that their blood glucose will not drop further if they wait or delay treatment. The fast should also be broken if blood glucose reaches <70 mg/dl (3.9 mmol/l) in the first few hours after the start of the fast, especially if insulin, sulfonylurea drugs, or meglitinide are taken at predawn. Finally, the fast should be broken if blood glucose exceeds 300 mg/dl (16.7 mmol/l). Patients should avoid fasting on “sick days.”
>Pre-Ramadan medical assessment and educational counseling
All patients with diabetes who wish to fast during Ramadan should undergo the necessary preparations to undertake the fast as safely as possible. These include medical assessment and educational counseling.
-Medical assessment
This assessment should take place within 1–2 months before Ramadan. Specific attention should be devoted to the overall well-being of the patient and to the control of their glycemia, blood pressure, and lipids. Appropriate blood studies should be ordered and evaluated. Specific medical advice must be provided to each individual patient concerning the potential risks they are accepting in deciding to fast, even if they fast against medical advice. During this assessment, necessary changes in their diet or medication regimen should be made so that the patient initiates fasting while being on a stable and effective program.
-Educational counseling
It is essential that the patients and family receive the necessary education concerning self-care, including signs and symptoms of hyper-and hypoglycemia, blood glucose monitoring, meal planning, physical activity, medication administration, and management of acute complications. Adequate nutrition and hydration should be emphasized, in addition to ensuring preparedness to treat hypoglycemia promptly should it occur, even if it is mild .
>Management of patients with type 1 diabetes
Close monitoring and frequent insulin dose adjustments in this setting are essential to achieve optimal glycemic control and avoid hypo- or hyperglycemia in patients with type 1 diabetes.
It is unlikely that one injection of intermediate- or long-acting insulin administered before the evening meal would provide adequate insulin coverage for 24 h.The doctor following the diabetic patient is the one able to plan the insulin injections and timings depending on the blood sugar control .
CONCLUSION:
Fasting during Ramadan for patients with diabetes carries a risk of an assortment of complications. In general, patients with type 1 diabetes should be strongly advised to not fast. Patients with type 1 diabetes who have a history of recurrent hypoglycemia or hypoglycemia unawareness or who are poorly controlled are at very high risk for developing severe hypoglycemia.On the other hand, an excessive reduction in the insulin dosage in these patients (to prevent hypoglycemia) may place them at risk for hyperglycemia and diabetic ketoacidosis.A patient’s decision to fast should be made after ample discussion with his or her physician concerning the risks involved. Patients who insist on fasting should undergo pre-Ramadan assessment and receive appropriate education and instructions related to physical activity, meal planning, glucose monitoring, and dosage and timing of medications. The management plan must be highly individualized. Close follow-up is essential to reduce the risk for development of complications.
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