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Eid said! It's Eid, marking the end of Ramadan!  I can't help but feel a little nostalgic for Michigan.  Even though I'm not Muslim, it can be fun to be swept up in a community's special time.

I'm not Christian either, in fact, I don't even really celebrate Christmas commercially anymore like my family did when we were children, but I still love watching A Christmas Story on TBS. I'll even admit that I enjoy a good slice of fruitcake every once and awhile (I do have standards though... only high quality fruitcake and usually with rum).

Similarly, it was such a privilege to be living in an area with a high enough concentration of Muslims that I could get a contact high.  You're reminded to be thoughtful about one's behavior and thoughts.  You're inspired to come together as a Muslim community, a local community, and a global community.  You congregate around food.  These are all things that I support.

For those of us who are not Muslim, Ramadan's most notable aspect is usually the month long fast that occurs while the sun is in the sky. Though the fast is only one portion of a larger theme of abstinence and purity, it's definitely one of the first things that comes to mind for me when I think of Ramadan.  And medically, though I'm sure actively trying to reduce the number of negative thoughts in your mind can reduce stress and thus promote wellness, it's the fasting component of Ramadan that needs to be discussed with my patients who have Diabetes.

It can be hard to predict what will happen when a person's eating schedule is disrupted by external forces.  Some simple observational studies reveal that about 15% of people lose weight during Ramadan, 15% gain weight, and the rest keep on keepin' on.

Our patients with Diabetes, however, can be at increased risk for health complications, particularly those who are on medications that modify their body's insulin or are completely insulin dependent.  Regardless of whether you have type 1 or type 2 diabetes, the major goal (and frequently difficulty) of insulin therapy is to adequately match the amount of insulin that your body needs with the amount and timing that you take.  Even during periods of typical eating, it can be a challenge because your body's insulin needs fluctuate with time and depends on a wide range of variables including when you last ate, what it was that you ate, the time of day, how quickly your insulin works, how long your insulin lasts for, and how active you are.  The consequences of mismatching your insulin dosing with your body's needs can range from the minor (slightly elevated blood sugar) to the catastrophic (blood sugar so low or so high that hospitalization is required).

Ramadan does allow for folks to opt out of the fast for health reasons.  Women who are pregnant, women on their period, the elderly frail, the ill, are all exempt from the fast (though making it up later might be required).  Certainly there are cases where it's obvious that someone shouldn't fast.  But when it comes to chronic diseases like diabetes it's a hazy call that's entwined with all the complications of life.  How well controlled are they outside of Ramadan? How well do they understand diabetes and their medical regiment?  Even more relevant is how important it is to them that they fast. Is it a critical religious and spiritual activity for them? Is it a unifying cultural practice? Are they worried that they will be judged by others if they don't fast? Will they judge themselves if they don't fast?

As clinicians, our approach to medical decision making varies widely from being directive in what we think our patients should do to being completely patient driven.  It's a judgement call we make based on each patient and the particular clinical scenario.  The decision to fast during Ramadan, unless we think it's extremely dangerous, is really one that should be left to the patient.  Our job is to give them the relevant medical information in a way that they can understand and then partner with them to help them reach their goals.  To that end I'll conclude with a paper!

There hasn't been much research on the best way to change insulin and medication regiments.  During Ramadan one usually fasts for at least 12 hours and then breaks the fast with a large meal when the sun sets. It's hard to match such large and extreme fluctuations.  A co-intern of mine recently showed me a great review article on Diabetes management during Ramadan.  The clinical take home points are summarized in the table below:
 


Naz
08/23/2012 15:21

you are my hero. awesome post.

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Malik P.
08/23/2012 21:15

Where is my Eid gift?

and yes.. I read your blog!

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