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ISLAMIC MEDICAL EDUCATION RESOURCES-04

0609- PUASA WITH DIABETES MELLITUS

Paper presented at a Diabetes Care Group Meeting held at the Multi-purpose Hall Block B, Suri Seri Begawan Hospital Kuala Belait Brunei on Tuesday 12th September by Professor Omar Hasan Kasule Sr. MB ChB (MUK), MPH (Harvard), DrPH (Harvard) Professor of Epidemiology and Islamic Medicine Universiti Brunei Darussalam EM omarkasule@yahoo.com, WEB: http://omarkasule.tripod.com

1.0 PUASA WITH PHYSIOLOGICAL IMPAIRMENTS

The following are allowed to break the puasa because of physiological weaknesses:  the elderly, al shaikh[i], the pregnant woman, al hublah[ii] if fasting is a risk to the health of the fetus and not the mother, the breast-feeding woman or nursing woman, al murdhi'[iii] if puasa is a risk to the health of the baby; and breast-feeding woman or nursing woman, al murdhi[iv] if puasa is a risk to the health of the mother, and the menstruating woman, al haidhah[v].

 

The very sick with chronic disease and the elderly do not undertake puasa but feed the poor instead[vi].. Those with curable diseases fast the missed days when they recover. The puasa of a sick person is valid but is makruh.

 

Diabetes mellitus being a physiological decompensation is covered under the general legal exemptions from puasa. However there are differences in the rulings depending on the type of disease. The rulings about puasa differ between insulin dependent and non-insulin dependent diabetics.

 

Insulin-dependent diabetics have to reduce their insulin dose because of reduced food intake during the day. In some cases this is not possible and they have to be exempted from fasting altogether especially if their diabetic control is brittle.

 

Non-insulin diabetics can undertake puasa under medical supervision. This will generally require changing times of medication, close monitoring of blood sugar levels, and being alert to any hyperglycemic or hypoglycemic crises.

 

Pregnant diabetics are exempted from fasting because diabetic control is more difficult in pregnant women making fasting doubly hazardous for both the mother and the fetus.

 

2.0 MEASURES TO PREVENT PHYSIOLOGICAL HARM:

The prophet (PBUH) taught measures to ensure that puasa does not cause physiologic damage. Puasa continuously from day to day, wisaal, was forbidden[vii]. Early iftaar was recommended[viii]. Delaying suhuur was recommended[ix].

 

3.0 MEDICAL GUIDELINES FOR PUASA:

The aim should be maintaining normal body weight or actually reducing it if overweight. Over-eating at iftaar and suhuur should be avoided. Over-eating will cause indigestion.

 

The diet should contain sufficient fiber to prevent constipation. Fiber and slowly digested foods with a long stomach transit times are preferred.

 

Enough water should be taken at night both for preventing dehydration and preventing constipation. Adequate fluid and salt intake prevents lethargy in the afternoon caused by low blood pressure.

 

Hunger is a cause of headache especially later in the day.

 

Intake of adequate calcium, magnesium, and potassium will prevent muscle cramps.

 

Hot places should be avoided. Attempts should be made to keep cool.

 

Inadequate sleep is a cause of headaches.

 

In non-diabetics hypoglycemia may be due to insulin overproduction on intake of refined sugar. In diabetics it may arise due to insulin injections with inadequate dietary intake.

 

 Peptic ulcers are aggravated by raised acid levels. Kidney stones may be due to low fluid intake. Joint pains may be due to excess solutes.

 

5.4 MEDICATION IN PUASA

The general rule is that any substance that enters the body through any of its openings, manfadh, nullifies puasa. The openings are the two ends of the alimentary canal, the mouth and the anus as well as the vagina.

 

All drugs that are applied externally on the skin do not nullify puasa. Sub-cutaneous, intra-muscular, and intra-venous injections do not nullify fasting. However nourishing injections nullify the purpose of puasa.

 

Drugs of whatever form taken orally, per anus, or per vagina nullify puasa.

 

Venepuncture does not nullify puasa.

 

Sub-lingual pills are allowed.

 

The medication schedule can be modified such that drugs are taken only during the night hours.

 

6.0 RECENT RESEARC ON PUASA AND DIABETES

6.1 Studies on the effect of puasa on diabetic control have given many contradictory results. This is due to lack of careful control for confounding factors and the general change in dietary habits that occurs in Ramadhan compared to other months of the year. We will here quote only 2 of such studies.

 

6.2 Azwany et al [x] studied the impact of Ramadan fasting on glycemic control in type 2 diabetes patients.   Forty-three Muslim type 2 diabetic patients or oral medication, with no renal or liver disease participated in the study. A total of 52 patients had been recruited giving a drop-out rate of 17.3%. Fasting blood glucose (FBG) and serum fructosamine levels were determined at four consecutive visits (at four weeks and one week before Ramadan, in the fourth week of Ramadan and four weeks after Ramadan). They found no significantly change in mean FBG over time (Figure 1, p=0.12). There was however an increase in fructosomine from the first to the fourth weeks (figure 2, p=0.001). The study showed poor diabetic control because the subjects were more hyperglycaemic in Ramadhan. They concluded that the poor control reflected lack of knowledge about adjusting diet and medication during Ramadhan.

 

6.3 Yousef et al[xi] undertook a study to study the effects of Ramadhan on various physiological parameters in normal and diabetic patients (NIDDM). The study group consisted of 53 diabetic patients (31 male and 22 female) and 56 (21 male 35 female) healthy volunteers as controls. The subjects were evaluated 1-2 weeks before commencement of fasting (visit 1), at the 4th week of Ramadan fasting (visit 2) and one month after the end of the Ramadan fast (visit 3). Results are shown in Tables 1 and 2. They found statistically significant weight reduction (P<.001) at the end of Ramadan fast in both groups which was not maintained one month after Ramadhan. Fasting blood sugar and HBA1C showed significant reduction (P<.001) among diabetics but not in control group. However serum cholesterol, triglyceride, and uric acid increased among healthy volunteers (control group) one month after Ramadan; no such changes were seen among diabetic group.


FIGURE 1: MEAN FBG (MMOL/L) IN 43 SUBJECTS BY WEEK IN RELATION TO RAMADAN


FIGURE 2: MEAN SERUM FRUCTOSAMINE LEVEL (mMOL/L) IN 43 SUBJECTS BY WEEK IN RELATION TO RAMADAN.

 

 

*Significant difference from 4th week of Ramadan p<0.001

 

 


TABLE 1: LABORATORY VALUES* TESTED AMONG DIABETIC PATIENTS AND CONTROLS BEFORE FASTING (VISIT 1) AND DURING RAMADAN (VISIT 2). Data is show  

 

Diabetic patients (n=53)

Controls (n=50)

                  

Visit 1

Visit 2

P value

Visit 1

Visit 2

P value

Weight(kg)

 

70.712.6

 

69.812.6

.012

60.613.7

58.612.4

.001

Fasting blood sugar (mmol/L)

10.64.1

8.5 3.4

.001

5.6 0.70

5.40 .71

NS

Cholesterol (mmol/L)

5.71.08

5.9 0.9

NS

5.4   0.9

5.6 0.9

NS

Triglyceride(mmol/L)

1.8 .93

1.7 0.9

NS

0.80 .51

0.8 0.6

NS

Urea(mmol/L)

4.2 1.5

4.52.3

NS

3.6 1.07

3.8 2.3

NS

Creatinine(mmol/L)

82.26

8628

NS

76.2 2.4

76.04 19

NS

Uric acid (micromol/L)

385134

37697

NS

281.3 85

290 77

NS

*all values are expressed as mean standard deviation

NS: not statistically significant

 


TABLE 2: LABORATORY VALUES* TESTED AMONG DIABETIC PATIENTS/ CONTROLS BEFORE FASTING (VISIT1) AND ONE MONTH AFTER FASTING (VISIT3):   

 

diabetic patients n=50

controls  n=48

 

 

 

Visit 1

 

Visit 3

 

P value

Visit 1

 

Visit 3

 

P value

Weight (Kg)

70.812.6

70.7 12.5

NS

60.513.8

59.113

NS

Fasting blood sugar (mmol/L)

10.84.1

9.063.8

.002

5.50.6

4.90.7

NS

HBA1C

7.352.03

6.71.6

.001

4.840.6

4.860.5

NS

Cholesterol(mmol/L)

5.71. 09

5.7 1.16

NS

5.5 1

5.8 1.16

.001

Triglyceride(mmol/L)

1.70.4

1.81.3

NS

0.780 .5

1. 0.6

.001

Urea(mmol/L)

4.11.4

52.5

NS

3.51

4.31.3

NS

Creatinine(mmol/L)

79.423

8126.3

NS

75.517

9022

NS

Uric acid (micro mol/L)

381136

365109

Ns

27884

32095

0.01

*all values are expressed as mean 7  standard deviation

 NS: not statis


[i] Bukhari K65 S2

[ii] Bukhari K65 S2 B25

[iii] Bukhari K65 S2 B25

[iv] Bukhari K65 S2 B25

[v] Bukhari K6 B6

[vi] Darqutni and Hakim)

[vii] Bukhari K30 B20

[viii] Bukhari K30 B45

[ix] Ahmad 5:147

[x] N. Azwany , Aziz A Ismail, W.B.W. Mohammad\,  A.K.Al-Mahmood.: Effect Of Ramadan Fasting On Glycemic Status Of Type 2 Diabetic Patients In Northern Malaysia. International Medical Journal Vol 2 No 2 December 2003

[xi] R M Yousuf, MD, A R M Fauzi, MRCP, S H How, M. Med, A Shah, MSc. Metabolic Changes During Ramadan Fasting In Normal People And Diabetic Patients. International Medical Journal Vol 2 No 2 December 2003

1.0 PUASA WITH PHYSIOLOGICAL IMPAIRMENTS

The following are allowed to break the puasa because of physiological weaknesses:  the elderly, al shaikh[i], the pregnant woman, al hublah[ii] if fasting is a risk to the health of the fetus and not the mother, the breast-feeding woman or nursing woman, al murdhi'[iii] if puasa is a risk to the health of the baby; and breast-feeding woman or nursing woman, al murdhi[iv] if puasa is a risk to the health of the mother, and the menstruating woman, al haidhah[v].

 

The very sick with chronic disease and the elderly do not undertake puasa but feed the poor instead[vi].. Those with curable diseases fast the missed days when they recover. The puasa of a sick person is valid but is makruh.

 

Diabetes mellitus being a physiological decompensation is covered under the general legal exemptions from puasa. However there are differences in the rulings depending on the type of disease. The rulings about puasa differ between insulin dependent and non-insulin dependent diabetics.

 

Insulin-dependent diabetics have to reduce their insulin dose because of reduced food intake during the day. In some cases this is not possible and they have to be exempted from fasting altogether especially if their diabetic control is brittle.

 

Non-insulin diabetics can undertake puasa under medical supervision. This will generally require changing times of medication, close monitoring of blood sugar levels, and being alert to any hyperglycemic or hypoglycemic crises.

 

Pregnant diabetics are exempted from fasting because diabetic control is more difficult in pregnant women making fasting doubly hazardous for both the mother and the fetus.

 

2.0 MEASURES TO PREVENT PHYSIOLOGICAL HARM:

The prophet (PBUH) taught measures to ensure that puasa does not cause physiologic damage. Puasa continuously from day to day, wisaal, was forbidden[vii]. Early iftaar was recommended[viii]. Delaying suhuur was recommended[ix].

 

3.0 MEDICAL GUIDELINES FOR PUASA:

The aim should be maintaining normal body weight or actually reducing it if overweight. Over-eating at iftaar and suhuur should be avoided. Over-eating will cause indigestion.

 

The diet should contain sufficient fiber to prevent constipation. Fiber and slowly digested foods with a long stomach transit times are preferred.

 

Enough water should be taken at night both for preventing dehydration and preventing constipation. Adequate fluid and salt intake prevents lethargy in the afternoon caused by low blood pressure.

 

Hunger is a cause of headache especially later in the day.

 

Intake of adequate calcium, magnesium, and potassium will prevent muscle cramps.

 

Hot places should be avoided. Attempts should be made to keep cool.

 

Inadequate sleep is a cause of headaches.

 

In non-diabetics hypoglycemia may be due to insulin overproduction on intake of refined sugar. In diabetics it may arise due to insulin injections with inadequate dietary intake.

 

 Peptic ulcers are aggravated by raised acid levels. Kidney stones may be due to low fluid intake. Joint pains may be due to excess solutes.

 

5.4 MEDICATION IN PUASA

The general rule is that any substance that enters the body through any of its openings, manfadh, nullifies puasa. The openings are the two ends of the alimentary canal, the mouth and the anus as well as the vagina.

 

All drugs that are applied externally on the skin do not nullify puasa. Sub-cutaneous, intra-muscular, and intra-venous injections do not nullify fasting. However nourishing injections nullify the purpose of puasa.

 

Drugs of whatever form taken orally, per anus, or per vagina nullify puasa.

 

Venepuncture does not nullify puasa.

 

Sub-lingual pills are allowed.

 

The medication schedule can be modified such that drugs are taken only during the night hours.

 

6.0 RECENT RESEARC ON PUASA AND DIABETES

6.1 Studies on the effect of puasa on diabetic control have given many contradictory results. This is due to lack of careful control for confounding factors and the general change in dietary habits that occurs in Ramadhan compared to other months of the year. We will here quote only 2 of such studies.

 

6.2 Azwany et al [x] studied the impact of Ramadan fasting on glycemic control in type 2 diabetes patients.   Forty-three Muslim type 2 diabetic patients or oral medication, with no renal or liver disease participated in the study. A total of 52 patients had been recruited giving a drop-out rate of 17.3%. Fasting blood glucose (FBG) and serum fructosamine levels were determined at four consecutive visits (at four weeks and one week before Ramadan, in the fourth week of Ramadan and four weeks after Ramadan). They found no significantly change in mean FBG over time (Figure 1, p=0.12). There was however an increase in fructosomine from the first to the fourth weeks (figure 2, p=0.001). The study showed poor diabetic control because the subjects were more hyperglycaemic in Ramadhan. They concluded that the poor control reflected lack of knowledge about adjusting diet and medication during Ramadhan.

 

6.3 Yousef et al[xi] undertook a study to study the effects of Ramadhan on various physiological parameters in normal and diabetic patients (NIDDM). The study group consisted of 53 diabetic patients (31 male and 22 female) and 56 (21 male 35 female) healthy volunteers as controls. The subjects were evaluated 1-2 weeks before commencement of fasting (visit 1), at the 4th week of Ramadan fasting (visit 2) and one month after the end of the Ramadan fast (visit 3). Results are shown in Tables 1 and 2. They found statistically significant weight reduction (P<.001) at the end of Ramadan fast in both groups which was not maintained one month after Ramadhan. Fasting blood sugar and HBA1C showed significant reduction (P<.001) among diabetics but not in control group. However serum cholesterol, triglyceride, and uric acid increased among healthy volunteers (control group) one month after Ramadan; no such changes were seen among diabetic group.


FIGURE 1: MEAN FBG (MMOL/L) IN 43 SUBJECTS BY WEEK IN RELATION TO RAMADAN


FIGURE 2: MEAN SERUM FRUCTOSAMINE LEVEL (mMOL/L) IN 43 SUBJECTS BY WEEK IN RELATION TO RAMADAN.

 

 

*Significant difference from 4th week of Ramadan p<0.001

 

 


TABLE 1: LABORATORY VALUES* TESTED AMONG DIABETIC PATIENTS AND CONTROLS BEFORE FASTING (VISIT 1) AND DURING RAMADAN (VISIT 2). Data is show  

 

Diabetic patients (n=53)

Controls (n=50)

                  

Visit 1

Visit 2

P value

Visit 1

Visit 2

P value

Weight(kg)

 

70.712.6

 

69.812.6

.012

60.613.7

58.612.4

.001

Fasting blood sugar (mmol/L)

10.64.1

8.5 3.4

.001

5.6 0.70

5.40 .71

NS

Cholesterol (mmol/L)

5.71.08

5.9 0.9

NS

5.4   0.9

5.6 0.9

NS

Triglyceride(mmol/L)

1.8 .93

1.7 0.9

NS

0.80 .51

0.8 0.6

NS

Urea(mmol/L)

4.2 1.5

4.52.3

NS

3.6 1.07

3.8 2.3

NS

Creatinine(mmol/L)

82.26

8628

NS

76.2 2.4

76.04 19

NS

Uric acid (micromol/L)

385134

37697

NS

281.3 85

290 77

NS

*all values are expressed as mean standard deviation

NS: not statistically significant

 


TABLE 2: LABORATORY VALUES* TESTED AMONG DIABETIC PATIENTS/ CONTROLS BEFORE FASTING (VISIT1) AND ONE MONTH AFTER FASTING (VISIT3):   

 

diabetic patients n=50

controls  n=48

 

 

 

Visit 1

 

Visit 3

 

P value

Visit 1

 

Visit 3

 

P value

Weight (Kg)

70.812.6

70.7 12.5

NS

60.513.8

59.113

NS

Fasting blood sugar (mmol/L)

10.84.1

9.063.8

.002

5.50.6

4.90.7

NS

HBA1C

7.352.03

6.71.6

.001

4.840.6

4.860.5

NS

Cholesterol(mmol/L)

5.71. 09

5.7 1.16

NS

5.5 1

5.8 1.16

.001

Triglyceride(mmol/L)

1.70.4

1.81.3

NS

0.780 .5

1. 0.6

.001

Urea(mmol/L)

4.11.4

52.5

NS

3.51

4.31.3

NS

Creatinine(mmol/L)

79.423

8126.3

NS

75.517

9022

NS

Uric acid (micro mol/L)

381136

365109

Ns

27884

32095

0.01

*all values are expressed as mean 7  standard deviation

 NS: not statis



[i] Bukhari K65 S2

[ii] Bukhari K65 S2 B25

[iii] Bukhari K65 S2 B25

[iv] Bukhari K65 S2 B25

[v] Bukhari K6 B6

[vi] Darqutni and Hakim)

[vii] Bukhari K30 B20

[viii] Bukhari K30 B45

[ix] Ahmad 5:147

[x] N. Azwany , Aziz A Ismail, W.B.W. Mohammad\,  A.K.Al-Mahmood.: Effect Of Ramadan Fasting On Glycemic Status Of Type 2 Diabetic Patients In Northern Malaysia. International Medical Journal Vol 2 No 2 December 2003

[xi] R M Yousuf, MD, A R M Fauzi, MRCP, S H How, M. Med, A Shah, MSc. Metabolic Changes During Ramadan Fasting In Normal People And Diabetic Patients. International Medical Journal Vol 2 No 2 December 2003

Professor Omar Hasan Kasule Sr. September 2006