Not so fast – diabetes in the Middle East

The International Diabetes Federation (IDF) calls the condition “one of the largest global emergencies of the 21st century”, and there is added concern for Muslims. Islam is the fastest growing religion in the world, and Muslim countries are disproportionately affected by this chronic disease; the number of diabetes sufferers in these areas is set to rise over the next 25 years.

The crisis is not about to abate any time soon either. With people living longer and leading more sedentary lives, and the rise in global obesity levels, the picture for the future of Middle Eastern health and diabetes is grim indeed.

The threat of diabetes grows even more ominous during the holy month of Ramadan. The period of sacrifice and religious commitment in Islam is seen as a chance to edify the soul. However, for those living with diabetes, the desire to participate can lead to severe health consequences if they are not suitably prepared and in regular consultation with healthcare professionals.

The IDF estimates that, of the 148 million Muslim diabetics worldwide, about 30% who participate in Ramadan also fast at other times of the year. The physiological effects of fasting can cause an already tenuously balanced endocrine system to tip into the arena of the unwell, especially patient’s with hypo or hyperglycaemia. Add to that the size of portions eaten and the food often being high in sugar and fat, and it is easy to see the lurking health risks.

The American Diabetes Association in 2015 revealed that the Middle East and North Africa have the second-highest comparative prevalence of diabetes. Deaths attributed to diabetes numbered 342,000 adults, with more than half of these younger than 60.

But the Middle East and North Africa are not to be singled out. The US and China have a high prevalence of diabetes and, according to 2015 statistics from Diabetes UK, the condition affects 3.5 million people in the UK, with that figure set to grow by another 1.5 million in the next ten years. Muslims living with diabetes in the UK are numbered at about 325,000 according to the ‘Diabetes and Fasting in Ramadan’ study published in GM Journal.

It is within this context that Dr Sarah Ali works. A diabetologist with more than ten years of experience, she says the topic affects her personally and professionally. “I am Muslim and I fast,” Ali reveals. “I know the implications of fasting from a spiritual point of view and from a health point of view.” The consultant at the Royal Free London NHS Foundation Trust says she has seen the dire changes to the body that diabetes can bring.

In 2013, Ali co-authored a practical health guide for the Muslim Council of Britain (MCB) for those fasting with diabetes during Ramadan. “I felt it was my duty,” she adds, “because I can see it from both sides. I understand the health implications but, at the same time, I understand why people have the desire to fast.”

Perception of health

It is important to note that the Quran does not demand that all Muslims fast. For instance, if someone is pregnant, has to travel, has kidney problems or other illnesses – such as diabetes – they are exempt. “They shouldn’t be deterred from abstaining,” Ali states. “There is religious authority on this. However, we know that fasting is a very spiritual and personal belief. There are many Muslims who have diabetes who do not perceive themselves as being unwell.”

Diabetics often do not present with symptoms – it could be the early stages of the condition’s onset, or they might be taking medication. The effects of diabetes are usually long-term, especially on the kidneys, eyes and
feet. Thinking of themselves as healthy can lead them to underestimate the dangers fasting can bring, with potentially grave complications.

It is essential, therefore, that doctors first present the facts to the patient about the potential implications of fasting. Next would be to study the patient’s medical history and garner their risk levels. “I want to stratify my patients,” Ali explains, “[according] to whether they are at low, moderate or high risk of complications while fasting.”

This stratification process depends on factors such as the type of medication and the size of the dose patients are taking, or whether they need only monitor their diet to keep their condition in check. Some medication makes people prone to low blood-sugar levels, as does insulin. Often, medication regimens need to be altered in the months leading to Ramadan in order for impending dietary changes to wreak less change on patients’ bodies.

“If they want to fast, and my advice is against that,” Ali says, “I would support them as best as I could because my duty is still to keep them safe.” According to her, it is important to consider the type of diabetes a patient has. If it is type 1 with insulin dependence, there tends to be greater complications. In this situation, Ali would advise against fasting: “It’s a balance between the risk of fasting and their spiritual benefits.”

Careful preparation

With such a lot at stake, it is important that doctors are equipped to counsel patients about their health, but also be able to address the pressing religious imperative driving them. Ali says that while the health sector is “not up to speed completely”, she is confident that non-Muslim doctors are able to tread delicately and sensitively to accommodate the needs of Muslim patients.

All doctors understand the consequences of fasting and the potentially enormous impact this has on those with diabetes. So, from a physical point of view, doctors are obviously qualified. However, Ali thinks there is growing awareness – in the West and, of course, in the East – about Islam’s fasting requirements through plenty of literature in peer-reviewed medical journals.

While doctors are more informed about the duality of spiritual needs and health imperatives, patients still need to know more. “Preparation is really paramount,” Ali stresses. With the proliferation of the internet and people’s access to information, Ali believes patients are arming themselves with knowledge of the implications of fasting.

If a Muslim has diabetes and is thinking about fasting, they should seek advice from their healthcare professional – whether that is a family doctor, diabetes doctor or diabetes nurse – and they should meet them as soon as possible, even several months before Ramadan.

Forming an open and communicative relationship with their healthcare provider will help keep them safe during Ramadan. The right preparation can lead to dietary and medical changes leading up to the fast as well as possibly doing a trial fast beforehand.

Vitally important is the need to test blood sugar levels throughout the fast. There is, unfortunately, a common misconception that doing so is forbidden, but Ali urges patients to check regularly. “It’s a small amount of blood,” she says, “and it won’t break your fast.” This is the consensus among healthcare practitioners and religious authorities alike.

Blood sugar levels should be checked before the fast begins and at least every four hours during the fast. Patients should be prepared to check more frequently if they develop symptoms or become unwell. In a practical guide published by the IDF in collaboration with the Diabetes and Ramadan (DAR) International Alliance, it is stated that by regularly measuring blood glucose, “Patients may become more conscious of their eating habits and the impact on their blood glucose levels, potentially curbing damaging behaviours.”

Alternative solutions

If a patient is advised not to fast, and heeds this caution, it is important that they know there are other ways to devote spiritual energies during this holy month. “They can participate in the extra prayers at night,” Ali suggests. “They can still be involved in mealtimes with their families, and they can participate in the additional Quran readings that most Muslims take part in during Ramadan.”

Those unable to fast can also give charity instead by paying for feeding someone during Ramadan. “That is something they can look into with their local imam,” Ali says. If they do improve their diabetes control, they could fast at different times of the year to make up for the fast if it is possible, but again that will be a discussion between them and their healthcare professionals.

“I think that last point is particularly important at the moment,” AIi adds, “because Ramadan falls in the summer in the northern hemisphere. The fast is very long and can be very hot, putting extra stress on the body and added risk on diabetes patients. It may, therefore, be more helpful to them if they fast outside of that month, and in winter, for example.

“If we advise them not to fast, they should appreciate that the reason we are saying this is because it will put their health at risk. The Holy Quran identifies these individuals as being exempt from fasting.”

Doctors are in a unique position when it comes to treating diabetes patients during Ramadan. There is a weighty balance that needs to be met, where patients can commit to their spiritual desires, but also remain healthy. With the proper amount of planning and making the health risks salient knowledge, many diabetic Muslims will be able to fast, honouring their religion and their bodies.