Diabetologists should educate HCPs, patients as well as religious scholars-Dr. Hassanein


 Diabetes and Ramadan

Diabetologists should educate HCPs,
patients as well as religious scholars-Dr. Hassanein

Last two hours of fasting has highest risk of hypoglycaemia
in patients with diabetes using sulfonylureas

Blood Glucose monitoring is recommended during Ramadan

KARACHI: Diabetologists need to educate not only the healthcare professionals, patients with diabetes but also the community leaders, politicians as well as religious leaders to create awareness about various questions which the patients with diabetes ask during Ramadan. This was stated by Dr. Mohamed Hassanein Consultant Diabetologist at Dubai Hospital and Senior Lecturer Cardiff University UK. He was speaking on “Educating healthcare providers on management of diabetes during Ramadan” at the formal launch ceremony of a special issue of Journal of Pakistan Medical Association on Diabetes and Ramadan. The meeting held at PMA House Karachi on May 8, 2015 was very well attended by healthcare professionals including some of the authors of the manuscripts published in the supplement.

In his presentation Dr. Mohamed Hassanein who is also chairperson of Diabetes and Ramadan International Alliance quoted different studies to highlight the problems faced by people with diabetes during fasting. CREED study which enrolled 3250 patinets, he said, showed that some people are unable to fast though they wish. It is the duty of the diabetes leadership to provide education on management of diabetes during fasting in different countries. There is increased risk of hypoglycaemia when the period of fasting is long. Timing of fasting and climate is different in different couriers during Ramadan. Many patients are on sulfonylureas and not every sulfonylurea is the same. There is increased risk of hypoglycaemia during last two hours of fasting in patients with diabetes who are on sulfonylurea, he added.


Dr. Mohamed Hassanein Consultant Diabetologist at Dubai Hospital who was the
chief guest at the formal launch ceremony of JPMA’s special issue on
Diabetes and Ramadan photographed along with Dr. Fatema Jawad
Editor-in-Chief of JPMA, Prof.Tipu Sultan, Prof. Abdul Basit,
Prof. Abdul Jabbar, Dr. Zaigham Abbas and PMA office bearers.
Some of the contributors to this issue are also seen in the picture.

During the month of Ramadan, there is exceptional use of diet, large meals with too many dishes and this fasting is turned into feasting. Fasting, in fact, he said, was to feel for the poor who remain hungry but it has gone in to the background. One of the studies showed that 59.5% people consumed large meals during Ramadan and the incidence of hyperglycemia increased by 3-5%. We have produced many documents and we need to produce Guidelines. Then every country should modify these guidelines to suit their local population keeping in view the local circumstances. Patients with diabetes can be described as very high risk, high risk and moderate risk to develop hypoglycaemia. Many patients are on insulin or sulfonylurea, old people are very ill. Those who have a history of hypoglycaemia or repeated episodes of hypoglycaemia are at a greater risk. Those who are well controlled on sulfonylurea and insulin have moderate risk but those who are controlled on diet and exercise alone has the lowest risk. CREED study also showed that 38% of people with diabetes did not stop fasting despite hypoglycaemia. Another study by Prof. Ahmedani showed that 48% of patients with diabetes practice fasting while suffering from hypoglycaemia. There are knowledge gaps between Muslim countries. Dr. Hasnnein was of the view that it is the job of Diabetologists to provide pre conception education to the women patients with diabetes. Educating of the Imams of the mosques, he further stated, was extremely important and we are doing it in UAE. We provide diabetes education at the mosques. We need to train the Imams of mosques, use all forums to educate the people and community at large. We also need to educate the people on meal planning, provide them dietary advice, advice on exercise and healthy diet. Patients with diabetes should be advised to use wheat, beans, rice. Blood glucose monitoring, he stated, was recommended during Ramadan and it does not break fast. These patients should be educated to recognize and then manage the complications.  One of the study showed that about 60% of patients with diabetes used to test their blood glucose one to three times during Ramadan. We need to have authentic guidelines on blood glucose monitoring during Ramadan. Another study showed that a vast majority of the patients with diabetes did not fast just after one hour of education educating them on the likely compilations. Another study showed that there was tremendous improvement in HbA1C in different cities while another study showed that almost 50% of the patient had to break their fast due to complications. We started a programme in Egypt and sent half a million SMS messages to the patients with diabetes and a similar experiment were done in Senegal. We can send them messages on life style modification. We should ask the patient how was their last Ramadan. Talk to the patient soon after Ramadan, it works and patients are very receptive. Sulfonylurea’s can cause hypoglycaemia hence DPP4 inhibitors can be used in Ramadan.

Continuing Dr. Hassnein said that some of the patients with diabetes may be at increased risk of hypoglycaemia or hyperglycemias. Hence, pre Ramadan assessment and education of these patients is extremely important. He also disclosed that IDF Guidelines on Fasting was now under preparation and there is lot of new evidence. These Guidelines will be finalized and will be available before Ramadan in 2016. Patients with renal insufficiency have high risk and together we can bridge the knowledge gap, he remarked.

Speaking on the occasion Prof. Abdul Basit Executive Director of Baqai Institute of Diabetes and Endocrinology (BIDE) said that we keep on learning all the time. There will be many guidelines; there will be some controversial issues. Kidney, heart diseases and other diseases in diabetics will result in more documents. What was more important was the implementation of these Guidelines and these should be discussed at different forums in the community.

Prof. Najmul Islam opined that events related to patients should be discussed and healthcare professionals should educate the patients with diabetes more and more. Dr. Naseem Salahuddin, Dr.Zaigham Abbas also spoke on the occasion and opined that using mobile phone educational messages can be sent to the patients with diabetes. Replying to a question Dr. Hassanein said that one of the studies showed that use of Insulin Pump with proper adjustment of dosage was Ok but still another study reported 17% incidence of hypoglycaemia with the use of Insulin Pump. Over eating during Ramadan end up with hyperglycemia. Responding to yet another question regarding use of nasal and ear drops by patients during Ramadan, Dr. Hassanein said that they should be OK but you need to talk to the religious leaders in the country and have their opinion because people listen to them more on religious issues. He also agreed that a dietician should be included in the team providing health education to the patients with diabetes. He laid emphasis on the fact that we need to modify the health education programmes to the local needs keeping in view the local culture. Dietary input and dietary service were extremely important, he added.

Earlier Prof. Idrees Adhi Chairman of the Editorial Board of JPMA in his speech commended the efforts of Dr.Fatema Jawad and her team in compiling and publishing the special issue of JPMA on Diabetes and Ramadan. This is a unique innovation in documentation in an era of Evidence Based medical practice. There is lot of literature available on Diabetes and Ramada and it will be a useful addition. He further stated that the concept of CME was commendable and it was very much needed but we have serious objections the way it has been introduced and was being implemented. We feel that to begin with a large number of healthcare institutions should have been asked to start such training programmes and in addition there should have been no money involved. This issue can be debated, he remarked.

Dr. Fatema Jawad Chief Editor of JPMA said that the special supplement includes three Editorials and twenty manuscripts covering a large number of topics. She emphasized on patient centered care for diabetes. Dr.Abdul Jabbar also briefly spoke on the occasion.