Muslim Religious Observances and Diabetes

Methods

The authors gathered information from the following sources: literature review; materials related to the topic that are available on EthnoMed; interviews with religious leaders, Harborview Medical Center physicians, Harborview Medical Center’s (Seattle) Multicultural Diabetes Team; and Harborview Medical Center caseworkers / cultural mediators.

Introduction

Islam is the religion of more than a billion Muslims throughout the world, comprising 18-25% of the world population. The Islamic faith necessitates strict observance of the injunctions of its holy book, the Koran, and the sayings and actions of the Prophet Muhammad. Muslims must fulfill a number of religious obligations, the essence of which is known as the five pillars of Islam:

• Stating one’s faith
• Praying five times a day
• Giving to the poor
• Fasting during Ramadan
• Making the pilgrimage to Mecca, the holy city of Islam in Saudi Arabia.

As one of the five pillars of Islam, Ramadan is believed to be the most blessed and spiritually beneficial month of the Islamic year. The classic Islamic point of view is that Ramadan fasting is good for the health and spiritual cleanliness of Muslims. Ramadan gives those fasting an opportunity to practice self-control and to obtain the rewards of God. For these reasons, many Muslims who are religiously exempted from fasting on the basis of being sick still insist on doing so, even against medical advice. These individuals will observe Ramadan fasting as long as they can, determined to participate fully with others in the excitement and spirituality of the month. 

Muslims who are diabetic face significant challenges managing their diabetes as fasting requires abstention from all food, fluids, oral medications, and IV fluids (medicinal and nutritional) during daylight hours.

Muslims may resist blood draws at this time in order to minimize fluid loss while fasting.

Ramadan Fasting

Ramadan is the obligatory fast for all healthy adult Muslims and children who have reached puberty that occurs in the ninth lunar month in the Islamic (Hijri) calendar. Throughout the month of Ramadan, food and drink may be consumed only after sunset and before sunrise (dawn) each day. Because it is based on moon cycles, the month of Ramadan can fall in any season of the year. Climatic conditions — especially heat — may physiologically influence fasting (Awad, 2001). 

In 2012 the estimated dates for Ramadan are July 20 through August 19. Those who are fasting may be doing so for over 18 hours a day, depending on their regional location, for an entire month. This has implications for those with diabetes and other serious health conditions, since Ramadan fasting requires abstention from all food, fluids, oral medications, and IV fluids during daylight hours.

Results of a 2001 study “Epidemiology of Diabetes and Ramadan (EPIDIAR)” showed that (among 12,243 Muslims with diabetes from 13 Islamic countries) 43% of T1DM patients and 79% of T2DM patients fast during Ramadan (Al-Arouj et al., 2010).

Children and Fasting

Muslim children who have reached puberty are obligated to fast during Ramadan. Prior to puberty, children are encouraged by their parents to practice fasting. Around the age of 7, children may fast a half-day or on weekends, increasing the length of the fast each year.

Exceptions from Fasting

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 (Al-Arouj et al., 2010).

In general, children who have not reached the age of puberty, sick persons, and pregnant or breastfeeding women are exempt from fasting. Muslim patients who fall into these categories are often resistant to being exempt from fasting because they do not “feel” sick and because of spiritual reasons and wanting to share this experience with their community. In lieu of fasting, some may choose to give alms to the poor, offer help in some other way to those in need, or make up the fast at a later date. According to the Koran, these are acceptable alternatives for those exempt from fasting.

It is also believed that women having their menstrual periods should not fast or pray. They must make up the fasting at a later date but do not have to make up the prayer.

Other actions that do not break fasting include unintentional vomiting; ingesting or inhaling things which are not possible to avoid such as one’s saliva or smoke; brushing the teeth; injections; and temporarily forgetting that one is fasting and inadvertently taking in nutrients, in which case one must proceed to complete the fast after the digression.

Breaking the Fast

After sunset on each day of Ramadan, prayers are offered and a meal called iftar is taken. Generally, this begins with one-half to one cup of water, followed by 3-7 dates eaten in the way that the Prophet Muhammad had practiced. It is said he ate them for a quick “sweet energy” source to ward off poor vision associated with fasting. Sweet drinks and high carbohydrate/high fat snacks like sambusa may be eaten next, followed by a meal consisting of pastas, meats, soups, vegetables, and breads. Ramadan fasting not only has spiritual significance but is also a time shared that enriches the sense of community.

A Harborview Medical Center Somali caseworker / cultural mediator reports that at iftar, some people eat less than they would at the main meal. A large amount of food after a long fast may cause nausea and feeling full happens sooner.

Suhoor is a much lighter meal taken before sunrise during Ramadan. Some typical foods consumed at suhoor are soor (grits) with milk, toast, porridge, and eggs.

To view more images and recipes of common Somali food, please see:

Other Fasting Practices

Some people will choose to fast an additional 6 days after Ramadan, beginning the day after Eid-al-Fitr (celebration marking the end of Ramadan).  This extra fasting is accepted by some Somali scholars as the equivalent of fasting for one entire year, while other Islamic scholars may say it is equal to 60 months (one day being equivalent to ten months). This type of fasting is called sunnah fasting.

There are other times when Somalis will fast as a common religious observance, one of which is the day prior to the festival of Ciid (pronounced “Eid al-Adha”) which falls approximately 70 days after the end of Ramadan. It is also called Adxaa (pronounced “haj”), which marks 10 days before the pilgrimage to Mecca. 

People who choose to fast throughout the year generally fast for periods of 2-6 days in a month, not usually exceeding 8 days a month.  

Many Muslims tend to shorten their working hours during Ramadan, and some may spend all of the fasting hours resting or sleeping.

In 2002, the men and women participating in Harborview Medical Center’s Multicultural Diabetes Project with Somali Immigrants (a program to help meet the needs of diabetic patients from Somalia via culturally tailored classes and materials) reported that they fast during Ramadan. Many felt there was no risk in fasting and none reported having experienced problems while doing so. They were aware of the exemptions but generally did not think that having diabetes meant being “really sick.” Most felt that fasting will heal a person, so even the really sick should fast if possible. They also pointed out that if they postponed the fast, they could make it up later or provide community service in lieu of it.

Important Note: The following two sections offer recommendations to providers concerning the management of diabetes in patients who fast.  EthnoMed is designed for educational purposes only and is not engaged in rendering specific medical advice or professional services. Any medical or other decisions should be made in consultation with doctors. Harborview Medical Center and the University of Washington Health Sciences Library will not be liable for any complication, injuries, or other medical accidents arising from or in connection with the use of or reliance upon any information in the web.

General Recommendations During Fasting

• It should be stressed that fasting — especially for those with type 1 diabetes and those who have type 2 diabetes with inadequately managed blood glucose levels — is associated with multiple risks including hypoglycemia, hyperglycemia, ketoacidosis, dehydration, low blood pressure, and thrombosis. Engage in a full discussion of the degree of the individual’s risk from fasting with the patient who intends to fast. For diabetes patients who prefer to fast, individualization of care and frequent monitoring of glycemic status is highly recommended.
• Patients often have experimented and developed their own regimen. Exploring this with the patient helps build a partnership between patient and provider, capitalizing on the knowledge of both parties.
• The following are some of the risk factors that may place patients at greater risk for complications from fasting. They are based on expert opinion and not scientific data (Al-Arouj, 2010):

• Very high risk – severe hypoglycemia or ketoacidosis within the last 3 months prior to Ramadan, history of recurrent hypoglycemia, hypoglycemia unawareness, history of sustained poor glycemic control, type 1 diabetes, pregnancy and need for chronic dialysis
• High risk – average blood glucose between 250-300 mg/dl or A1C > 9.0%, renal insufficiency, advanced macrovascular complications, old age with ill health, living alone, and treatment with insulin or sulfonylureas with no adjustment in dose to accommodate fasting
• The diet during Ramadan should not differ significantly from the recommended balanced diet. According to Al-Arouj (2010) over half of individuals who fast maintain their body weight, 20-25% lose weight (sometimes up to 3 Kg), and the rest gain weight. The common practice of ingesting large amounts of foods rich in carbohydrate and fat at the sunset meal should be moderated. This includes limiting sweetened foods and avoiding excessive eating with 2-3 meals in the nighttime hours.
• Because of the delay in digestion and absorption, ingestion of foods containing “complex” carbohydrates is especially encouraged at the predawn meal, while foods with more simple carbohydrates are more safely consumed at the sunset meal.
• It is recommended that water intake be increased during the non-fasting hours.
• Normal levels of physical activity may be maintained, but excessive levels may lead to higher risk of hypoglycemia and dehydration and should be avoided.
• Patients should avoid fasting on “sick days.”
• It is essential that people with diabetes understand that they must end their fast immediately in the following cases:

• If blood glucose level drops dramatically to < 60 mg/dL or increases to >300 mg/dL
• If blood glucose level drops to < 70 mg/dl in the first few hours after the start of the fast, especially if the usual doses of insulin, sulfonylurea drugs or meglitinide are taken at predawn.
• If symptoms of diabetic ketoacidosis appear
• Advise patients to wear a Medic Alert bracelet and to carry glucose tablets with them.
• Muslim patients do not typically visit their diabetes clinics for follow-up during Ramadan. This may pose challenges to care management but can be remedied through simple educational measures at pre-Ramadan visits. Assess knowledge of symptoms of hypo and hyperglycemia, blood glucose monitoring, insulin/medication action and durations, carb counting ability, and effects of physical activity on blood glucose. Instruct as needed in these areas. Achieving good glycemic control before Ramadan reduces the risks associated with fasting (Sheikh and Wallia, 2007).
  

Medication Management

• Pre-Ramadan medical assessment and educational counseling should be provided for all diabetic patients. Advise patients to monitor BG more frequently during fasting periods. Patients unwilling to monitor BG have a much higher incidence of complications. Take into account how long the fast will last. Incorporate the patient’s experiences with BG control when fasting in previous years into current treatment recommendations.

Some of the options followed by practitioners for type 1 diabetics include: 

• Well controlled T1DM patients currently using multiple daily injections of insulin or insulin pump therapy would not need much changed, other than a modest reduction in basal insulin and matching the prandial insulin to the timing of meals.
• One daily injection of the long-acting insulin analog Glargine, or twice-daily injections of the insulin analog Detemir. The dose is reduced to 2/3 the original.
• If the patient can count carbs, consider prescribing pre-meal rapid-acting insulin analogs adjusted to the carb content of their meals. Patients who make large changes to their insulin regimens should be advised to see their primary care provider during the fast.
• A less optimal option is two daily injections of NPH intermediate-acting insulin, one before the sunrise meal and one before the sunset meal. Reduce the sunrise dose to 1/2 the usual dose and keep the sunset at full dose. This will decrease the risk of hypoglycemia around midday due to peaking of the early morning insulin dose, but patients should still be made fully aware of this possibility.
• Some patients will eat a small “lunch” meal at midnight. Those with T1DM may need to take a small dose of rapid acting insulin with this meal. If insulin is taken, then the patient should be advised to check a BG in 2-4 hours after the meal.
•  If the patient has an insulin pump, fasting provides an excellent opportunity for “basal testing.” The patient would simply keep basal insulin rate and bolus/correction timed with meals.

Some options for type 2 diabetics that have been recommended are as follows:

• For those well controlled with diet alone – distribute calories over 2-3 smaller meals during the non-fasting interval and exercise 2-3 hours after the sunset meal to help prevent excessive postprandial hyperglycemia.
• Exercise should be modified in its intensity during daylight hours.
• Those who take metformin may typically fast safely because the possibility of hypoglycemia is minimal. However, the timing of the doses should be modified: 2/3 of the total daily dose immediately after the sunset meal and 1/3 before the sunrise meal.
• Those on insulin sensitizers like glitazones, DPP-4s (-gliptin) and GLP-1 agonists have low risk of hypoglycemia and the dosing is usually not changed.
• Because normoglycemic DKA has been reported in patients taking SGLT-2s (-flozin) when NPO prior to surgery, flozins should be discontinued for the period of fasting.
• Sulfonylureas are generally considered not suitable for use during fasting because of the inherent risk of hypoglycemia. They should be used with caution. Consider switching to the short-acting sulfonylureas, regaplitide or nateglinide taken twice daily with meals, usually prescribing a smaller dose with the pre-dawn meal.
• Those who use insulin face similar problems as type 1 diabetics. The general aim is to maintain necessary levels of basal insulin to remedy the prevailing relative deficiency and to overcome the existing insulin resistance; however, insulin resistance is decreased in the fasting state. Some patients may only need a single dose of NPH insulin with the sunset meal or 2/3rds of their pre-Ramadan basal prandial dosing — similar adjustments as described for T1DM patients during fasting (see above). Special caution is advised for patients who require >60 units of insulin/day and who are obese as they may need even less than a 2/3rds reduction in TDD as fasting will not only significantly reduce total calories but will reduce insulin resistance as well. T2DM patients at greatest risk of complications are those with insulin deficiency, obesity, and the very elderly (Al-Arouj, 2010).
• Consider a lower dose of anti-hypertensive medication during fasting to prevent hypotension related to dehydration during daytime hours, especially if Ramadan occurs during hot weather. However, most patients who need cholesterol lowering medications will continue to benefit from them during Ramadan, as the food eaten at the sunset meal typically has high saturated fat content (Al-AArouj 2010).

Additional Resources

This article, written by 14 Muslim physicians from around the world, is an excellent resource for clinicians. It was published in 2005 and updated in 2010 in the American Diabetes Association’s journal Diabetes Care.

References

Sansal, Burak. The Five Pillars of Islam, http://www.allaboutturkey.com/5pillar.htm, accessed August 2008 by Multicultural Diabetes Team, Harborview Medical Center.

Al-Arouj M, et al. Recommendations for Management of Diabetes during Ramadan, Diabetes Care, August 2010, Vol. 33(8), pp. 1895-1902. (An excellent resource written by 14 Muslim physicians.)

American Diabetes Association: The Glimepiride in Ramadan Study Group (GLIRA): The Efficacy and Safety of Glimepiride in the Management of Type 2 Diabetes in Muslim Patients During Ramadan, Diabetes Care, February 2005, Vol. 28(2), pp. 421-422.

Greenhalgh T, et al. Sharing stories: complex intervention for diabetes education in minority ethnic groups who do not speak English, BMJ, 2005, Vol. 330, pp. 7492-628.

Salti I, et al. A Population-based Study of Diabetes and Its Characteristics during the Fasting Month of Ramadan in 13 Countries: Results of the Epidemiology of Diabetes and Ramadan 1422/2001 (EPIDIAR) Study, Diabetes Care, October 2004, Vol. 27(10), pp. 2306-2311.

Unpublished data: Notes from diabetes classes for Somali women (2003) and men (2005) held at Harborview Medical Center by diabetes educators, pharmacists, dieticians and cultural mediators.

Unpublished data: Interviews with religious leaders, Somali physicians and cultural mediators of factors affecting Somali diabetics. Harborview Medical Center, Multicultural Diabetes Team, 2003.

Ramadan – The Blessed Month, http://www.islam-mauritius.org/ramadan.htm, accessed August 2002 by Multicultural Diabetes Team, Harborview Medical Center.

Ahmed, A. Ramadan Fasting: Impact on Diabetes Mellitus and Guidelines for Care, Practical Diabetology, 2001, Vol. 9, pp. 7-15.

Davila, Florangela. Food and Fasting in Somali Culture, 2001, EthnoMed web site:

Haq, Aliya. Report on Somali Diet, 2003, EthnoMed web site: https://ethnomed.org/clinical/nutrition/somali-diet-excerpts/?searchterm=fasting

Sheikh, Aziz and Wallia, Sunita. Ramadan and Fasting. BMJ, 2007, 335:613-614