Fasting and Feasting : A SouthAsian Perspective Dr Wasim Hanif MD FRCPUK Consultant Physician

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Fasting and Feasting A South-Asian Perspective
 Dr Wasim Hanif MD FRCP(UK)
Consultant Physician Honorary Senior
Lecturer University Hospital Birmingham
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• 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

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Fasting

• 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

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Introduction

• 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

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Five 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

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Ramadan

• 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)

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Diabetes 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

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For whom is fasting mandatory?

• Muslim
• Adult ( reached puberty)
• Sane
• Not in a state of travel
• Women ( Not menstruating or post natal)

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Exemptions 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)

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• God likes his permission to be fulfilled, as he
  likes his will to be executed.
• Prophet Mohammad PBUH

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Exemptions From Fasting

• Old age
• Infirm
• Illness
• Travel

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Counteregulatory hormones
FFA, Ketones
Adipose
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Hyperglycaemia Ketoacidosis
Counteregulatory hormones Glucagon
FFA, Ketones
Adipose
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Exemptions From Fasting International consensus
meeting held in Morocco 1995

• Type 1 diabetes
• Type 2 diabetes unstable disease
• Diabetes with complications
• Pregnant
• Elderly

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Exemptions 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)

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EPIDIAR 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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EPIDIAR 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
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Salti et al Diabetes Care Vol 27 10 Oct 2004
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Major risk associated with fasting in diabetes

• Hypoglycaemia
• Hyperglycaemia
• Diabetic Ketoacidosis
• Dehydration and Thrombosis

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Recommendations 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
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Management General Consideration

• Individualization
• Frequent Monitoring of Glycaemia

Al-Arouj et al Diabetes Care Vol 28 9 Sep 2005
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Al-Arouj et al Diabetes Care Vol 28 9 Sep 2005
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Nutrition

• 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

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Exercise

• 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

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Breaking 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

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Pre-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

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Pre-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

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Medical Assessment

• Hba1c
• Blood pressure
• Lipids
• Specific advice including risk to health if
  fasting against medical advice
• Changes to diet and medication

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Educational Counselling

• Self Care
• Symptoms of Hypo and Hyperglycaemia
• Blood glucose monitoring
• Meal planning
• Physical activity
• Medication administration
• Management of acute complications

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Management of Type 1 Diabetes
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Management of Type 1 Diabetes
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Management 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

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Management 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

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South-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

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Recommendations 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

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Feasting in South Asians
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Feasting 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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• Acknowledgments
• Dr Vinod Patel
• Consultant Physician
• University of Warwick
• Dr Paramjit Gill
• Senior Lecturer
• University of Birmingham