Title: Fasting and Feasting : A SouthAsian Perspective Dr Wasim Hanif MD FRCPUK Consultant Physician
1Fasting and Feasting A South-Asian Perspective
Dr Wasim Hanif MD FRCP(UK)
Consultant Physician Honorary Senior
Lecturer University Hospital Birmingham
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3- Why do people fast and what does fasting involve?
- The evidence base of fasting in diabetes and the
challenges - Guidance for fasting in diabetes
- A bit of feasting
4Fasting
- Islam one month from dawn to dusk in Ramadan when
no food or water is consumed - Hinduism fast frequently between one and nine
days and some may fast one day of week but the
fast varies
5Introduction
- Diabetes affects 22 of the Pakistani Muslim and
27 of the Bangladeshi Muslim population (aged 25
74). - The size of the British Muslim community is
estimated by some to be approx. 1.6 million. 3
6Five Pillars
- Islam has basic duties, which Muslims must
perform. They are known as the 5 pillars of Islam
2,3 - - 1. Shahadah / Kulma The declaration
of faith - 2. Salah / Namaz Five compulsory
daily prayers - 3. Zakat Annual alms tax,poor and
needy - 4. Sawm
Fasting during Ramadan month - 5. Hajj Pilgrimage to Mecca
- The Shahadah is intended to be a constant
presence, the day is punctuated by 5 prayers,
whilst zakat and fasting occur annually the Hajj
coming once in a life time.2
7Ramadan
- O ye who believe! Fasting is prescribed to you as
it was prescribed to those before you, that ye
may (learn) self-restraint, - (Qur'an el Hakeem, 2183)
- Ramadan is the month in which was sent down the
Qur'an as a guide to humanity and as a clear sign
for guidance and judgment (between right and
wrong). So anyone of you who witnesses the month
should spend it in fasting..." (Al-Qur'an, 2185)
8Diabetes and Ramadan
- It is an act of abstaining from food and drink
from dawn through to sunset. This also involves
abstaining from intravenous fluids, intravenous
medication and oral, aural and nasal. - The two meals are Sehri (pre-sunrise) and Iftari
(after sunset)2-6 - Fasting is said to cultivate the spirit of
sacrifice and teaches Muslims moral and self
discipline, and sympathy for the hungry and
poor.4 - Islam follows the lunar calendar and hence the
month of Ramadan can vary from between 29 30
days. In Britain a fast can last for up to 19
hours during the summer months, and 10hours
during the winter months
9For whom is fasting mandatory?
- Muslim
- Adult ( reached puberty)
- Sane
- Not in a state of travel
- Women ( Not menstruating or post natal)
10Exemptions From Fasting
- " Nor kill (or destroy) yourselves, for Allah has
been to you Most Merciful." (Al-Qur'an, 429) - And make not your own hands contribute to
(your) destruction..." (Al-Qur'an, 2195) - "Your soul, indeed, has rights on you!" (Bukhari)
Among its rights is your protecting it from harm. - "Fasting is for a fixed number of days, but if
any of you is ill, or on a journey, the
prescribed number (missed) should be made up..."
(Al-Qur'an, 2184)
11- God likes his permission to be fulfilled, as he
likes his will to be executed. - Prophet Mohammad PBUH
12Exemptions From Fasting
- Old age
- Infirm
- Illness
- Travel
13Counteregulatory hormones
FFA, Ketones
Adipose
14Hyperglycaemia Ketoacidosis
Counteregulatory hormones Glucagon
FFA, Ketones
Adipose
15Exemptions From Fasting International consensus
meeting held in Morocco 1995
- Type 1 diabetes
- Type 2 diabetes unstable disease
- Diabetes with complications
- Pregnant
- Elderly
16Exemptions From Fasting
- Fasting during Ramadan by a Muslim diabetic
patient is neither his right nor Islamic
obligation, but only a privilege to be allowed by
his physician, at the patient's request, knowing
all the dangers and assuming full responsibility
in dietary compliance and glucose monitoring,
with good communication between the physician and
the patient . - Shahid Athar MD (Islam-USA.Com)
17EPIDIAR STUDY
- A retrospective study conducted in thirteen
countries of 12,914 patients with diabetes - 8.7 had type1 and rest type 2 diabetes
- Population based survey
- Algeria, Bangladesh, Egypt, India, Indonesia,
Jordan, Lebanon, Malaysia, Morocco, Pakistan,
Saudi Arabia, Tunisia and Turkey
Salti et al Diabetes Care Vol 27 10 Oct 2004
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19EPIDIAR STUDY
- 42.8 of patients with type 1 diabetes
- and
- 78.7 of patients with type 2 diabetes
- Fasted for at least 15 days in Ramadan
Salti et al Diabetes Care Vol 27 10 Oct 2004
20Salti et al Diabetes Care Vol 27 10 Oct 2004
21Major risk associated with fasting in diabetes
- Hypoglycaemia
- Hyperglycaemia
- Diabetic Ketoacidosis
- Dehydration and Thrombosis
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23Recommendations following EPIDIAR expert group
- Open dialogue on this important topic
- Offer a set of medical opinions and suggestions
- To identify topics of research
Al-Arouj et al Diabetes Care Vol 28 9 Sep 2005
24Management General Consideration
- Individualization
- Frequent Monitoring of Glycaemia
Al-Arouj et al Diabetes Care Vol 28 9 Sep 2005
25Al-Arouj et al Diabetes Care Vol 28 9 Sep 2005
26Nutrition
- 50 to 60 maintain body weight while 20 to 25
gain or loose weight - Maintain healthy diet
- Eat complex carbohydrate advised at dawn meal
more simple carbohydrates at dusk - Avoid food high in fat and sugar
27Exercise
- Normal level of exercise should be maintained
- Extreme physical activity should be avoided
before sunset - If taraweeh prayers are being offered to be a
part of regular exercise programme
28Breaking the Fast
- Patients should break fast if blood glucose less
than 3.5 mmol/L - If less than 4 mmol/L in first few hours after
the start of fasting especially if on insulin or
sulfonylureas - If blood glucose greater than 16.7 mmol/L
- Avoid fasting on sick days
29Pre-Ramadan medical assessment and counselling
- In EPIDIAR study 68 of patients with type 1 and
62 of patients with type 2 diabetes pre-Ramadan
advice - Bain et al from Birmingham UK only 40 of
patients received any pre-Ramadan counselling
30Pre-Ramadan medical assessment and counselling
- All diabetic patients wishing to fast should
receive counselling 1 to 2 months before the
onset of fasting - Medical assessment
- Educational Counselling
31Medical Assessment
- Hba1c
- Blood pressure
- Lipids
- Specific advice including risk to health if
fasting against medical advice - Changes to diet and medication
32Educational Counselling
- Self Care
- Symptoms of Hypo and Hyperglycaemia
- Blood glucose monitoring
- Meal planning
- Physical activity
- Medication administration
- Management of acute complications
33Management of Type 1 Diabetes
34Management of Type 1 Diabetes
35Management of type 2 diabetes RamadanPre
During
- Patient on diet and exercise
- Metformin 500mg Tds or SR
- TZDs
- Sus once a day Glicalzide MR 60 mg and
Glimipride 4mg
- No change needed
- Metformin 1gm at dusk meal and 500mg at dawn meal
- No change needed
- Dose to be given at Dusk meal adjust for
hypoglycaemia
36Management of type 2 diabetes RamadanPre
During
- Mix 70/30 eg 30units morning and 20 units evening
- Use the morning dose at dusk meal and half the
evening dose at dawn eg 30 units and 20 units - Consider changing to Glargine or Determir with
bolus doses of Lispro and Aspart
37South-Asian Diabetes CareThe Alphabet Strategy
- Advice exercise, diet, not smoking, regular
clinics - Blood Pressure aim less than 140/80
- Cholesterol TC less than 5, LDL lt 3, HDlgt 0.9
- Diabetes Control
- HbA1c 7 or less
- Eyes check yearly at least refer appropriately
- Feet check yearly at least refer appropriately
- Guardian Drugs
- Aspirin 75mg, ACE-I, AT II antagonists, statins
38Recommendations from SAHF
- Education of patients and health care
professional about fasting - Uniform advice
- Pre Ramadan assessment
- Research to identify best practice and guidance
and studies looking at short term and long term
effects of fasting
39Feasting in South Asians
40Feasting in South Asians
- Pongal
- Holi
- Ramnavami
- Krishna Navami
- Rakshah Bandhan
- Nag Panchami
- Baisakhi
- Vinayak Chatruthi
- Durga Puja
- Navarathri
- Dashera
- Diwali
- Guru Nanak Birthday
- Eid
- Bakrid
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42- Acknowledgments
- Dr Vinod Patel
- Consultant Physician
- University of Warwick
- Dr Paramjit Gill
- Senior Lecturer
- University of Birmingham