We should establish a network of Muslim countries and organize symposium on Ramadan and Health every two years - Dr. Mohsen Nemat


Symposium on Ramadan and Health at DIMC

We should establish a network of Muslim countries
and organize symposium on Ramadan and
Health every two years - Dr. Mohsen Nematy

Adequate sleep, healthy balanced diet, adequate fluids, attention
to iron rich foods is essential for good health - Prof. Jasem Ramadan

KARACHI: We need to establish a network of Muslim countries and organize symposium on Ramadan and Health after every two years. There is also a need to have a separate chapter on fasting in our medical text books. This was stated by Dr. Mohsen Nematy from Mashad University of Medical Sciences, Iran. He was delivering a keynote lecture on results of preliminary studies on Ramadan Fasting: the evidence and expert’s opinion at the first scientific session of symposium of Ramada and Health organized at Dow International Medical College DUHS Ojha Camps on October 26th 2013. This session was jointly chaired by Prof. Nighat Nisar, Prof. Nazeer Khan and Mr. Shaukat Ali Jawaid.
Fasting, Dr. Mohsen Nematy said was not harmful for health. However, we need to study its health related effects in different regions due to variation in temperature. Furthermore there are different food habits in different regions, change in sleep pattern also have its effects. Hence the effects of fasting in patients suffering from coronary heart diseases, epilepsy, kidney diseases, IHD, Fatty Liver and many other disorders needs to be investigated in detail. However, no one is prepared to provide funding for performing studies related to Ramadan. He then gave highlights from different studies conducted so far and said that they have showed that with fasting there is improvement in coronary heart disease risk in ten years, there is reduction in fat and weight loss. Studies have also shown that there are no clinical changes in symptoms of asthma patients, while thyroid hormone levels remained normal despite significant reduction in T3 in the fasting group. We need to conduct further studies to find out how fasting affects different diseases as regards their symptoms, complications, morbidity etc. He also disclosed that they have recently started a Journal on Fasting and Health to publish research studies related to this topic.

Senator Haseeb Khan (Guest of Honour) presenting mementoe to Prof.Ramadan from Kuwait (left) and
Dr.Mohsen Nematy from Iran (right) during the Ramadan and Health Symposium. Also seen in the picture
from (L to R) are Prof.Naazeer Khan, Prof.Masood Hameed Khan VC DUHS and
Prof. Zaman Sheikh former Director of NIDE.

Prof. A.H. Amir from Hayatabad Medical Complex Peshawar in his invited lecture on Ramadan and Physiology said that with fasting there is slight fall in serum glucose (60mg) there is decrease in insulin, total cholesterol and TGs in fasting but then they return to pre fasting levels. What we eat at Sehar and Iftar during Ramadan matters a lot and there are various regional differences. Studies have shown that fasting leads to increase in HDL, increase in uric acid after prolonged fasting, there is slight rise in bilirubin, there is fall in gastric secretions and weight loss has also been reported in Ramadan but then it is linked to what one eats at Sehar and Iftar. Different studies have also shown affects of weather in fasting; decrease in appetite has also been noticed while fewer suicides have been reported during the month of Ramadan. Patients with GI diseases, Bladder disorders, ulcer, renal transplant patients, cardiac and pulmonary diseases, women during pregnancy and menstruation period are exempt from fasting. Change in weather will affect the results of studies hence it should be kept in mind while planning these studies. High risk patients include those with severe hypoglycemia, pregnancy, dialysis, repeated episodes of hypoglycemia, ketoacidosis three months before Ramadan, renal insufficiency and those living alone.
Prof. Yakoob Ahmedani from Baqai Institute of Diabetes and Endocrinology (BIDE) made a presentation on Ramadan and Diabetes. He pointed out that over fifty million Muslims all over the world fast. Some time ago investigators from thirteen Muslim countries got together to discuss the risks and complications of fasting and came to the conclusion that it is safe for patients with diabetes to fast, both type one and type two but drug dosage needs to be altered. This EPIDIAR study showed that 64% of patients did not change their insulin dosage during fasting and no acute diabetic complication was observed during Ramadan. Majority of the patients in different studies had no serious acute complication and none of the diabetics developed diabetic ketoacidosis. (DKA). Another study showed that 18.4% of patients had no change in their medications. He was of the view that it is mandatory to alter the dose of oral hypoglycemic agents as well as insulin during Ramadan. In the study which they conducted, 30% of the diabetics were not monitoring their blood glucose during Ramadan. Despite hypoglycemic episodes, they continued to fast. He opined that if the blood glucose is below 60mg/dl, the patient must breakfast but if it is over 300mg/dl they should consult their doctor. Patients education, he said was extremely important that is why BIDE has now established a Ramadan Study Group.

Prof. Nighat Nisar along with Prof.Nazeer Khan and Mr.Shaukat Ali Jawaid
chairing one of the scientific sessions during Ramzan and Health
Symposium organized by DUHS at DIMC last month.

Dr. Shabeen Naz Masood Consultant Obstetrician and Gynaecologist from Karachi talked about Ramadan Fasting practices of people with diabetes and gave highlights of a study they conducted on 1050 urban diabetics. Patients who did not fast for two years were excluded. The study included 33% male and 67% females with mean age of 51 years. Almost 78% were obese and overweight, 62% had no hypoglycemic symptoms, 18% continued to fast despite hypoglycemic episodes. Just 0.3% broke their fast due to hypogylcaemic episodes. Fasting glucose was safe in patients with type 2 diabetes without any serious complications. She suggested that if there is critically low blood glucose the patients should be advised to break the fast.
Prof. Nazli Hussain Prof. of Obstetrics and Gynaecology at DUHS discussed the effects of maternal Ramadan fasting on fetal growth. She pointed out that few studies are available on neonatal outcome in diabetics who are fasting. One hundred women were included in this study, fifty who were fasting and fifty who were not fasting. Only singleton pregnancy was included . High risk pregnancy and multiple pregnancies were excluded. The study showed there was no effect on fetal growth in pregnant women with diabetes. Others who spoke in this session included Dr. Masood Hussain Rao, Nafisa Bano Mustafa, Kashif Shafique and Dr.Fareeduddin.
Summing up the session Mr. Shaukat Ali Jawaid Chief Editor of Pulse International and Pakistan Journal of Medical Sciences highlighted the salient points from the key note speaker and invited speakers. He further stated that we do want to encourage research but it was also important to provide training facilities and funding for these studies. Referring to the situation in our neighboring country Iran, he said that they have forty five medical universities which are all the time competing with each others as regards their research publications and academic output. They have separate Vice Chancellors for Research who provide facilities and funding for research. Faculty members are encouraged to plan, conduct and publish studies atleast one paper every year. Those who fail are warned during the first year and if they fail to publish for the second year, they are removed from the faculty position. Iran spends over 7% of its GDP on Health and enough funds are provided to medical universities for Research. There is a lot to learn from Iran for healthcare professionals from Pakistan in various fields related to health services and medical education, he added.
Continuing he advised the organizers to be careful and give due importance to time management. Usually what happens is that we start late, the speakers do not stick to their timings and then no time is left for discussion which is extremely important. Many a time’s most important issues are highlighted during the discussion and it also provides a chance to the audience to participant in the deliberations. Speakers should avoid repetition, know how to prepare slides and make a presentation. Refrain from reading from the slides, each slide should not have more than six lines and it should contain just points which the speakers should use to make the presentation. If the slide is too busy, just highlight the points you wish to focus so that the message is conveyed effectively, he remarked.
Prof. Jasem Ramadan along with Dr. Mohsen Nematy and Prof. Khanani chaired the second scientific session. Prof. Jasem Ramadan from Dept.of Physiology, Faculty of Medicine, and The Health Services Center at Kuwait University, Kuwait was the first speaker who gave a keynote speech on Ramadan Fasting, Exercise and Physical activity. Is it healthy or Risky? To begin with he pointed out that after such a delicious lunch, the cardiac output goes down to the stomach and one feels sleepy. Hence, he asked the participants to stand up, do a few exercises stretching their arms and legs few times so that their cardiac output increases and goes to their brain so that they are all awake to which every one obliged.
He then stated that there used to be very few papers on the subjects of Ramadan and Health, Ramadan and Exercise till late 70s but from 80s onward, the number of studies and publications increased manifold and now lot of research work was being undertaken by many researcher. One of the studies has showed that if you have no energy, you perform better. Yet another athlete confirmed that his best performance was during Ramadan. All this shows the benefits of Fasting. Changes in serum lipids, he said, is variable and depends on the quality and quantity of food intake, physical activity and exercise besides changes in body weight. Well controlled type 2 diabetics and compliant may observe Ramadan fasting but fasting is not recommended for pregnant, diabetics with type-1 non compliant, poorly controlled diabetics. There are no adverse effects of Ramadan fasting on respiratory and cardiovascular systems, hematologic profile, endocrine and neuropsychiatric functions. Those patients suffering from various diseases should consult their physicians and follow medical and scientific recommendations when they wish to fast. Otherwise fasting is safe for all healthy individuals. He emphasized the importance of adequate sleep, healthy balanced diet, adequate fluids, and attention to iron rich foods besides attention to specific needs of different sports to remain healthy. Future research needs to be done on competitive performance measures, Prof. Jasem added.
Prof. Zaman Sheikh discussed which anti diabetic medications are safe during Ramadan. He pointed out that there are two types of drugs, glucose dependent and glucose independent. Hypoglycaemia occurs in 0.20% of patients taking Metformin. However, severe hypoglycemia has not been reported unless used in combination with other drugs. TZP2 can increase hypo effects. Some of the anti diabetic drugs results in weight gain, macular edema and bone fracture in post menopausal women. Meglitimides have short duration of action. We are afraid of using sulfonylurea’s during Ramadan. He then briefly mentioned about the safety and efficacy of Gliptins.
Prof. Zaman Sheikh then gave highlights from the study they had conducted. The study lasted for twelve weeks one month before and one month after Ramadan. Patients with past history of DKA, pregnant, breast feeding women were excluded. Similarly those suffering from severe diabetic retinopathy and night shift workers were also excluded. Forty one patients in Group-1 and forty patients in Group-2 completed the study. The study showed that Glargin insulin, he said, has slightly better control as compared to Sitaglipton as regards mean reduction of HbA1c, fasting blood sugar, and PPG but as regards hypoglycemic events, both groups are comparable. Judicious use of DPP4 and basal insulin’s are equally effective, he remarked.
Dr. Khaidja Irfan Khawaja from Services Institute of Medical Sciences Lahore was the next invited speaker in this session. She talked about fasting safely and feasting wisely with diabetes. She pointed out that there are excessive discrepancies and uneven meal spacing during Ramadan. During fasting one may suffer from hypoglycemic episodes, myocardial infarction and stroke may also occur if one is not careful with medications. Patients need to be educated when to check their blood glucose during Ramadan. There is an increased risk of hypoglycemia with tight control of blood glucose. It is very expensive to conduct studies on continuous glucose monitoring (CGM) during Ramadan. She then gave the results of the study they conducted. Patients were divided into four group’s i.e. Diet alone, Metformin alone, Metformin and sulfonylurea’s, Sita plus Metformin. Moderate silent hypogylcaemic episodes were noted in all the four groups. Addition of Acarbose did slightly reduce the hypoglycemia but there was no overall improvement.
Management of diabetes during Ramadan is fraught with challenges. Potential risks associated with fasting in diabetic subjects, she said, include wide glycaemic and metabolic parameters including DKA, hypoglycemia and dehydration. Most current guidelines advice caution while allowing diabetics to fast. She opined that it was the duty of the treating physician to advice the patient to fast safely by imparting education and selecting appropriate treatment regimens.
Prof. Masroor Ahmad Principal DIMC along with Dr. Khuram Shahid and Dr. Akhtar Baloch chaired the next session. Dr. Najmul Islam Prof. of Medicine at Aga Khan University was the first speaker who made a presentation on medical management of obesity. Defining obesity he said it means excessive accumulation of fat in the body. In Asia the suggested BMI waist circumference for men is under 90cm and for women under 80cm.Men with more than 35 inch Waist Hip ratio is considered obese. Studies have shown that over 2.8 million people die due to obesity annually the world over and it is a growing problem. It is associated with diseases like hypertension, diabetes, stroke, infertility and many other disorders. Anti psychotics, anti depressants, anti convulsants, certain anti diabetic drugs, antihistamines, steroid hormones, beta adrenergic blockers all result in weight gain. Reduction in weight leads to reduction in blood pressure and it also reduces diabetes besides increase in HDL.
Speaking about treatment of obesity, he mentioned life style interventions, exercise therapy and behaviour therapy. Drugs used for treatment include thyroid hormones, fenfluramine. Currently phentermine, topiramate, serotonin agonists, cannibinoid receptors antagonists are the known anti obesity preparations. Lorcaserin has been approved by FDA for obesity treatment but if there is no response after twelve weeks, this drug must be withdrawn immediately. Combination of Phenteramine-Topiramate is used for long term treatment of obesity. It also reduces HbA1c but dry mouth is one of the known side effects. Short term weight loss has been shown by some antidepressants and many new molecules are now in various stages of development. Bariatric surgery is also safe and effective in managing obesity. As regards Ramadan and obesity, he stated that fasting improves all aspects of health. Ms. Amina, Mr. Riasat and Dr. Jibran Saleh were the other presenters in this session.
In his concluding remarks Prof. Masroor Ahmad said that some of these small studies have given some observations but certainly no strong recommendations can be made based on these studies. Dr. Khurum Shahid in his remarks advised the speakers to refrain from reading the slides, have minimum points on each slide and involve the audience otherwise no one will listen to them.