Ramadan and Fasting presentation notes

May 22, 2014, we had a presentation on Ramadan and fasting, by Ali Chatour, Raman Virk, Satvir Malhi, Dr Hanan Bassyouni, and Ruchi Chopra

The following are notes from the presentation taken by Dave Dyjur:

Fasting is a tradition common to many cultures, including Christians, Hindus, Muslims and others. It can present challenges to people with diabetes and the healthcare providers they turn to for advice. The following notes provide some of the points I took away from the presentation:

·         What people mean by a fast varies, and so it is important to check with people to clarify exactly what they mean when they say they intend to fast.

·         Generally, Muslims will avoid food, water, and every other ingested substance, during daylight hours, for the month of Ramadan.

o   The time of year of Ramadan varies, as it is based on the lunar calendar.

o   Some people will stick strictly to the guideline regarding daylight hours in the location where they live, however in more northerly latitudes, in the summer, some may go by the time in Mecca.

o   Fasting during Ramadan is personal, and intentional. People will try to use the time to get closer to their faith, and to do good works for others.

·         Generally, during Ramadan, there are 2 meals:

o   Suhur is eaten before sunrise. For many people this is a very small meal, but for some, can be quite large. It is important to check.

o   Iftar is eaten after sunset. In many cases, this is a large meal, or can even be a series of snacks/meals, which can total quite a large amount of carbohydrate.

·         Ruchi brought a number of foods to illustrate the potential carbohydrate load someone might get at iftar (the evening meal). Everyone's eyes were wide when they saw the size of the naan bread she brought in. I estimated it to be well over 200 g of carbohydrate for the whole thing. This would be eaten by an entire family, so the amount each person gets would depend on a number of factors, of course, but it points out the need to clarify the amount eaten, rather than simply accepting someone who says they eat ½ a bread.

o   Ruchi provided a useful way to gauge the amount of carbohydrate a person might be getting from homemade breads, e.g. roti. Asking about how many roti the person is able to make from 1 cup of flour can help. Every cup of flour represents 6 starch choices (90 g carbohydrate). In some cultures, 1 cup of flour typically makes 2 or 3 rotis, or in others, might make 6 rotis. Each roti could be 1 to 3 or even more starches (15 to 45 g carb, or more), so it is important to check.

·         Dr Bassyouni reviewed the physiology of fasting, outside of diabetes, and reviewed some of the research into the metabolic effects of fasting. She did stress that there are not any high quality studies of the effects of fasting during Ramadan, however, the studies have shown (outside of diabetes):

o   No harmful effects on lipids (perhaps even a slight improvement in HDL), BP, coagulation status (even a small improvement in d-dimer), acute coronary syndrome incidence, or CVA/TIA.

o   No detrimental effect to the IQ of children born to mothers who fasted during pregnancy.

·         She reviewed the physiology of fasting during Ramadan in people with diabetes. Again, there are not good quality research studies in the literature.

o   Fasting in the absence of insulin causes increased glycogen breakdown and ketogenesis, so can cause hyperglycemia and ketoacidosis.

o   There is a potential for hypoglycaemia as well, of course.

o   Acknowledging methodological problems, the EPIDIAR study showed more reported severe hypoglycaemia during Ramadan, which was more frequent in those who changed there medication regime. Is this because they did not change it appropriately?

·         Outside of pregnancy, Dr Bassyouni offered the following tips regarding medications:

o   In type 1 diabetes

§  People on an insulin pump can usually handle a fast more easily.

§  Use of a longer acting analogue, with rapid insulin at meals, can be a safe strategy.

o   In type 2 diabetes

§  Metformin is safe to use.

§  Longer acting insulin secretagogues are riskier than the shorter acting ones (e.g. repaglinide).

·         If having a low, people must treat the low glucose reading, regardless of trying to fast.

o   Stress to patients that they can make up for the breaking of the fast by fasting on another day, if desired.

o   Responding to someone who doesn't want to treat a low blood glucose, do not give them a choice - they must treat it.

·         Muslims need not fast if they are pregnant or ill or have diabetes.

o   They can make up days, or even the entire time, at a different time of the year, if desired.

o   Breastfeeding or being pregnant, is a "license" to be able to skip the fast.

o   It is not disrespectful to point out to someone that they need not fast.

o   Fasting is a personal decision, and deciding to not fast does not result in pressure from peers or others in the community. It was pointed out, however, that often people put the pressure on themselves, and may still choose to fast.

·         In pregnancy, Dr Bassyouni pointed out that she flatly tells people with type 1 diabetes that they will not fast, and discourages fasting in GDM. In GDM, she may agree to a trial of fasting, if the woman insists.

o   Defining when to check for a "fasting" glucose level can be problematic. The testing regime is up to the doctor, of course, but a fasting glucose level might best be done before iftar (the evening meal).