Diabetes in Ramadan

Islam is the second largest religion in Britain, after Christianity. In 2001, the number of Muslims in Britain was around 2.5 million. Devoted healthy Muslims commemorate the revelation of the Holy Quran by Allah to the Prophet Mohammed by fasting in the month of Ramadan every year. Ramadan lasts for 29 or 30 days, depending on the sighting of the moon. While continuing their daily occupation without time off, fasting Muslims abstain from food, liquids, tobacco, sexual activity and medication (oral, inhaler or injection) from sunrise to sunset. However, the sick, the pregnant and nursing mothers and children are exempt; moreover, if a fasting person becomes ill, he or she is allowed to end the fast in the day.

Ramadan directly influences the control of diabetes because of the month-long changes in meal times, types of foods, use of medication and daily lifestyle^1,2. Doctors and nurses who encounter Muslim diabetic patients need to understand the practicalities. What does a controlled diabetic Muslim do in Ramadan that a health professional should know about?

CUSTOMS IN RAMADAN

The religious goal of enhancing physical, psychological, social and spiritual wellbeing is achieved by the following daily customs.

Physical activities

In Ramadan a Muslim fasts from dawn to dusk and ends the fast with dates (or prunes if dates are not available) and water or juice.

Iftari, a big evening meal with extra sweet and savoury foods, but still a balanced diet, is taken after the sunset prayer.

Men walk to the local mosque for night prayer whilst most women pray at home (for reasons of safety).

Sehri, a light meal is taken before sunrise. Some Muslims omit this meal so as not to disturb their non-Muslim neighbours. This may contribute to hypoglycaemia during the day.

Psychological activities

Prayer and meditation—which are akin to group therapy—result in self-audit and relaxation.

Religious leaders, elders and colleagues of the same sex provide counselling.

Social activities

Friends and relatives are invited to iftari, making it a feast and social event.

Sick friends and relatives are visited, with sharing of the care as appropriate.

Spiritual activities

Taraveeh is a special night prayer: standing in the mosque the Muslim listens to the Holy Quran. A hafiz (who has the Holy Quran by heart) recites all 30 chapters of the Holy Quran through the month.

There is extra listening to sermons, and the Muslim becomes more pious and sensitive; he or she feels more guilty if a religious taboo is broken, even by medication. This guilt may be accompanied by self-disgust and spiritual pain—very unpleasant.

TEN POINTS TOWARDS IMPROVING DIABETES CARE IN MUSLIM PATIENTS

A Muslim may be devoted, liberal or secular; assess carefully how religiously devoted your patient is. Health professionals are also human and may have negative feelings about Muslims. Referral to another doctor will sometimes help both parties; take it or leave it, but do not proceed half-heartedly. Communication with the patient begins with respecting names. Even if they do not show it, many will be upset if you write Muslim as Moslem and Quran as Koran, if you use initials instead of full first and middle names (because these have religious connotations) and if you ask ‘what is your Christian name?’. These cultural issues, and the minutiae of diabetes management, have been discussed elsewhere^3,4,5. Here are ten practical points.

1. Ramadan fasting improves diabetes by lowering the blood glucose and HbA1c because of fewer post-prandial peaks. Adjust medication if necessary

2. Meditation and prayers tend to lower blood pressure. Adjust the dosage of antihypertensive drugs in a hypertensive patient

3. Pork and non-halal meat are absolute taboos in Islam. Thus pork insulins, pork-based synthetic insulins, and beef (non-halal) insulins are unacceptable to devoted Muslims. Non-porcine synthetic (human) insulin should be given in preference. If a forbidden insulin is the only choice, a religious leader or doctor should be encouraged to mediate and reduce the patient's guilt feeling and spiritual pain. These advisers would use the doctrine of ‘the sanctity of life’, permissible in Islam. It means that life must be saved at all cost

4. ‘Human insulin’ may be misunderstood by the patient as signifying manufacture from human flesh or pancreas, leading to non-compliance. Some non-westernized Asian and African Muslims do not understand diabetes as western people do. Explain that ‘human’ simply means ‘akin to human’

5. In Ramadan, a person with type 2 diabetes can take a sulphonylurea at the end of the fast, with the evening meal started within 30 minutes. Advise not to miss the sehri (before sunrise) meal so as to avoid hypoglycaemia later in the day. Repaglinide (NovoNorm) can be particularly useful, since it need only be taken when a meal is eaten, therefore no change in drug therapy will be required in Ramadan. A meal must be eaten within 15 minutes

6. The patient may concurrently be taking alternative medicine from a hakim (a Muslim healer) e.g. karela powder (an oral hypoglycaemic). Ask the patient, and adjust medication or advise accordingly

7. Glycaemic foods should be taken into account. Muslim sweets taken in Ramadan, khir (rice pudding) and vermicelli are sugary and may necessitate a change in drug therapy. Savoury foods such as karela (a vegetable), onion and garlic are hypoglycaemic. Again, adjustment of medication or dietary tips may be needed

8. Medical advice is sometimes ignored for religious reasons. Occasionally a devoted Muslim will say, ‘Allah will protect me’. He or she may not fear death or may even want to die so as to meet the Creator. Counsel the patient by saying ‘to see the doctor and comply with treatment is Prophet Mohammad's sunnat (precedent)’. To refuse would be a sin

9. Article 9 of the 1998 Human Rights Act, which came into force on 2 October 2000, requires freedom of thought, conscience and religion. This has been incorporated in English and Scottish law and all general practitioners and hospital doctors are bound by it.

I hope that general practices and hospital clinics will use these notes as a starting point for drawing up guidelines according to local needs and circumstances.