‘Ramadan’ is derived from the Arabic word ‘ramida or ‘ar-ramad’, which means scorching heat or dryness. It is the ninth month of the Islamic calendar and is observed by Muslims worldwide as a month of fasting to commemorate the first revelation of the Quran to Prophet Muhammad (PBUH) according to Islamic belief.

This annual observance is regarded to be very holy and one of the Five Pillars of Islam. The month lasts 29–30 days based on the visual sightings of the crescent moon, ending with Eid al-fitr. While fasting from dawn until sunset, Muslims refrain from consuming food, drinking liquids, smoking, taking oral or injectable medications and engaging in sexual relations. Fasting for Muslims during Ramadan typically includes the increased offering of prayers and recitation of the Quran. Food consumption is divided into 2-3 meals per day, with ‘Iftar’ being the meal at sunset and ‘Suhoor’ / ‘Sehri’ being the predawn meal. The fasting period varies according to the geographic location. In UAE this year, the average fasting period will be 15 hours, with average temperatures of 45 degree Celsius. Fasting during the scorching summer heat with unpleasant humid conditions will pose a challenge, especially to people working outdoors.

Fasting in Ramadan is mandatory for all adult Muslims according to Islam. Worldwide, it is estimated that over 50 million people with diabetes fast for Ramadan. The EPIDAR (Epidemiology of Diabetes and Ramadan) study showed that 43% of patients with Type1 DM and 79% of patients with Type2 DM fast during Ramadan. However, certain guidelines have been laid down in the holy Quran, wherein certain categories are exempted (The Holy Quran, Al-Bakarah, 183-185). These include any ill person, children, women who are pregnant, lactating or menstruating, travelers and people with reduced mental capacity.

Diabetics, especially the high-risk patients come under the above exempted category as they stand a major risk of developing hypoglycemia, hyperglycemia, diabetic ketoacidosis, dehydration and thrombosis. According to the American Diabetes Association (ADA) Update 2010, the very high to high risk diabetic patients include those with severe or repeated hypoglycemias, hypoglycemia unawareness, uncontrolled diabetes, Type1 DM, ketoacidosis, acute illness, performing intense physical labor, pregnancy, advanced diabetic complications like renal failure on dialysis, patients on sulphonylureas and insulin (especially those living alone) and old age with ill health. Religious sentiments should always be respected, however, the decision to permit to fast should be based on the above medical consensus.

Healthy, well-controlled diabetics are permitted to fast. Before undertaking the fast, these patients should visit their treating doctors, who will counsel them regarding the adjustment of the dose and the timings of their medications and insulin. They should also be counseled by the dietician regarding the diet in Ramadan to prevent hypoglycemias during the fasting period and sudden spikes of blood sugars after Iftar. Gastric upsets (gastritis and GERD) are very common in Ramadan. These are triggered by long fasting hours, overeating during Iftar, sleeping immediately after Suhoor, consuming large quantities of caffeinated beverages and oily, deep-fried or spicy foods. Moderation while ending the fast and delaying Suhoor can help prevent such digestive disorders. At all times, adequate fluid intake should be ensured during the non-fasting hours.

Modifications to treatment regimens usually instituted pre-Ramadan, are once again aimed at preventing blood sugar fluctuations during Ramadan. It is imperative to educate the patients that carrying out blood investigations or frequently self-monitoring blood sugars during the fasting period is allowed and doesn’t amount to breaking of the fast. This way they can keep a track of their blood sugars and be confident of fasting uninterruptedly. Patients should break their fast if their blood sugars drop below 65mg/dl or exceed 290mg/dl.

With a multi-disciplinary approach, we can enable a greater number of believers to fast successfully and fulfill their commitment. Believers should observe the true spirit of Ramadan, which is a time of spiritual reflection, improvement and increased devotion and worship. It is meant to cleanse the soul by freeing it from harmful impurities. It teaches to practice self-discipline, self-control, sacrifice and empathy, encouraging charity. It should indeed be a month of ‘fasting’ and definitely not ‘feasting’ as this will defeat its very purpose.

RAMADAN KAREEM!

DR. PRAKASH S. PANIA
CONSULTANT ENDOCRINOLOGIST
ASTER JUBILEE MEDICAL COMPLEX, BUR DUBAI