Experiences of people with type 1 diabetes fasting Ramadan following structured education: A qualitative study

Experiences of fasting during Ramadan in British Muslims: Psychological, social and health behaviours

Ramadan is a month-long religious festival observed by Muslim worldwide, characterised by intermittent fasting. This qualitative study addressed the need to understand how fasting is experienced by Muslims residing in Western cultures, aiming to inform policies that create a more supportive environment. Practicing Muslims, both men and women, were recruited in the North of England in the United Kingdom (UK). Data were collected by individual interviews (N = 7) and focus group discussion (N = 4) and then analysed using Social Ecological Theory as a framework. Fasting was managed at the individual level through instrumental food choice and eating practices, and by adapting sleep routines. Disrupted sleep routines posed a challenge for those who had to adhere to Western working schedules, leading to perceived detriments to cognitive function and mood. The sense of belonging associated with Ramadan was seen as a motivating factor for fasting. Breaking the fast (Iftar) was marked by social activity and the availability of traditional fried foods. Participants identified the wider Western culture and environment as challenging for those who are fasting. These findings imply a need for policies that enable flexible working practices for Muslims during Ramadan.

Caloric and Lipid Profiles in the Spanish Population of North Africa

This study introduces an analysis for determining factors of diet quality among the Spanish adult population in North Africa with the aim of promoting healthier eating habits to prevent the development of diabetes mellitus. It is a diagnostic, non-experimental, cross-sectional and observational study, with a descriptive correlational methodology, with 201 participants from Ceuta and Melilla. The information collection has been carried out through the 24 h diet recall. Various sociodemographic factors influencing the quality of the diet have been analyzed. People from Melilla adopt a carbohydrate-rich diet (p = 0.004), whereas people from Ceuta have a lipid-rich diet (p = 0.002), particularly a high- monounsaturated-fat diet (p = 0.007). Muslims consume more sugar (p = 0.001) compared with Christians. Those working consume less carbohydrates (p = 0.13) than those not working. The latter consuming more fats (p = 0.39), and those with a higher education level show higher consumption of proteins (p = 0.001). The results of this study suggest that diet quality, in general, does not follow healthy recommendations established for the Spanish population, where the sugar consumption-diabetes relationship justifies the need for further research on Muslim population.

Evidence-based risk factors for major complications during Ramadan fasting in people with diabetes grouped under IDF-DAR risk categories

AIM

To identify evidence-based risk factors for major complications during Ramadan fasting in people with diabetes grouped under IDF-DAR risk categories.

METHODS

This prospective observational multicenter study was conducted by Baqai Institute of Diabetology and Endocrinology (BIDE) between April-June 2019. People with diabetes having intention to fast during Ramadan were recruited. Demographic data collection along with risk categorization was done during pre-Ramadan visit. Structured education was given on one- to-one basis to each of the study participants. Assessment of complications was done during post Ramadan visit.

RESULTS

A total of 1045 people with diabetes participated with near equal gender distribution. Two thirds of study population was grouped into very high- and high-risk categories. Frequencies of major hypoglycemia, major hyperglycemia, hospitalization & need to break the fast were 4.4%, 10.8%, 0.8% & 3.1% respectively. On multivariate analysis, the risk factors found for major hypoglycemia during Ramadan were male gender, use of sedatives & antidepressants & having type1 diabetes mellitus, history of DKA/HHS during last 3 months for major hyperglycemia, major hypoglycemia & hospitalization for breaking of fast while older age, acute illness, and major hypoglycemia were identified factors for hospitalization.

CONCLUSION

In this prospective study evidence-based risk factors for fasting related major complications were identified in people with diabetes. It is imperative to recognize these factors during pre-Ramadan risk assessment visit.

Exploring the experiences and perceptions of haemodialysis patients observing Ramadan fasting: a qualitative study

BACKGROUND

The festival of Ramadan is a month of spiritual reflection for Muslims worldwide. During Ramadan, Muslims are required to refrain from eating and drinking during daylight hours. Although exempted from fasting, many patients undergoing maintenance haemodialysis (HD) opt to participate in this religious practice. Many studies have explored the effects of Ramadan on health outcomes, however, the exploration from patients' own point of view pertaining to this religious practice is lacking. Thus, we aimed to explore the experiences and perceptions of Muslim HD patients observing Ramadan fasting from three HD centres in Klang Valley, Malaysia.

METHOD

An exploratory phenomenology qualitative study was conducted whereby subjects were purposively selected based on previous experience in observing Ramadan fasting. Face-to-face in-depth interviews were conducted, and study data were analyzed thematically and iteratively coded using a constant comparison method.

RESULTS

Four major themes emerged from the data, namely: (i) "fasting experiences", (ii) "perceived side effects of fasting", (iii) "health-seeking behavior" and, (iv) "education and awareness needs". Patients expressed the significance of Ramadan fasting as well as the perceived impact of fasting on their health. Additionally, there is lack of health-seeking behaviour observed among patients thus, raising needs for awareness and education related to Ramadan fasting.

CONCLUSIONS

Findings of this study shed light on patients' experiences and perceptions regarding Ramadan fasting which warrants the needs for an effective communication between patients and health care practitioners through a structured-Ramadan specific education program.

Ramadan fasting and diabetes 2019: The year in review

INTRODUCTION

The literature on health aspects of Ramadan fasting is widely spread in many journals making it not readily available to those interested in the subject.

MATERIALS AND METHODS

A narrative, non-systematic review of the international literature from two major online databases (viz. Scopus, PubMed) in one year (2019). The search term "Ramadan fasting AND Diabetes" was used, and relevant literature was narrated in a concise thematic account.

RESULTS

Research design included qualitative, quantitative, and mixed methods. Articles included controlled trials, critical appraisals, literature narrations, and systematic reviews, and meta-analyses. The publications spanned a vast array of topics related to Ramadan fasting, including assessments of current safety and efficacy profiles of newer diabetes therapies, modes of insulin delivery, and utilization of advanced technology for the treatment and monitoring of blood glucose during Ramadan fasting. Increased interest was particularly evident in capturing the experience element manifested by perceptions, attitudes, and practices of both patients and healthcare professionals during Ramadan. The current literature consolidates previous data on the safety of fasting practices amongst the well-controlled. On the other hand, it emphasizes the need for more aggressive interventions for high-risk patients, promoting the usage of newer anti-diabetic agents and advanced glucose monitoring technology for safer fasting practices.

CONCLUSIONS

The volume of global literature production related to Ramadan fasting and Diabetes remains modest. Observational studies of small size prevail. Greater improvements in both quality and quantity of research on Ramadan are needed.

Experiences and views of people with diabetes during Ramadan fasting: A qualitative meta-synthesis

OBJECTIVES

To review and appraise the existing qualitative studies on Ramadan fasting in participants with diabetes and to integrate valuable qualitative evidence for optimizing diabetes management.

METHODS

Twelve databases (PubMed, Embase, Cochrane Library, Science Direct, CINAHL, PsycINFO, JBI (Joanna Briggs institute), Web of Science, and four Chinese databases) were searched to identify qualitative studies on experiences and perspectives of Ramadan fasting in participants with diabetes. CASP (Critical Appraisal Skills Program) Qualitative Checklists were applied to appraise the included studies. A meta-synthesis approach was used to analyze the included studies. Through the strategy of inductive thematic synthesis and reciprocal interpretation, the findings and quotations of the included studies were integrated into new themes and categories. The CERQual (Confidence in the Evidence from Reviews of Qualitative Research) tool was used to grade the confidence of the new themes.

RESULTS

A total of 11 qualitative studies were included, and 43 findings were isolated. Ten new themes were identified and synthesized from the findings. Finally, four new categories were integrated, including the knowledge and understanding of observing Ramadan fasting, well-being and challenges, self-efficacy, and needs and expectations of participants with diabetes during Ramadan.

CONCLUSIONS

Insulin-dependent individuals call for special concern during Ramadan fasting. Ramadan-focused education needs to be developed and generalized, and existing guidelines should be improved to optimize the management of diabetes. Professional HCPs contribute to weigh the health risks and mental satisfaction for their patients, partly, to balance health and religion. Participants' psychological construction is another concern for religious scholars and psychologists.

Ramadan and Diabetes: A Narrative Review and Practice Update

Fasting in the Islamic month of Ramadan is obligatory for all sane, healthy adult Muslims. The length of the day varies significantly in temperate regions-typically lasting ≥ 18 h during peak summer in the UK. The synodic nature of the Islamic calendar means that Ramadan migrates across all four seasons over an approximately 33-year cycle. Despite valid exemptions, there is an intense desire to fast during this month, even among those who are considered to be at high risk, including many individuals with diabetes mellitus. In this review we explore the current scientific and clinical evidence on fasting in patients with diabetes mellitus, focussing on type 2 diabetes mellitus and type 1 diabetes mellitus, with brief reviews on pregnancy, pancreatic diabetes, bariatric surgery, the elderly population and current practice guidelines. We also make recommendations on the management of diabetes patients during the month of Ramadan. Many patients admit to a do-it-yourself approach to diabetes mellitus management during Ramadan, largely due to an under-appreciation of the risks and implications of the rigors of fasting on their health. Part of the issue may also lie with a healthcare professional's perceived inability to grasp the religious sensitivities of Muslims in relation to disease management. Thus, the pre-Ramadan assessment is crucial to ensure a safe Ramadan experience. Diabetes patients can be risk-stratified from low, medium to high or very high risk during the pre-Ramadan assessment and counselled accordingly. Those who are assessed to be at high to very high risk are advised not to fast. The current COVID-19 pandemic upgrades those in the high-risk category to very high risk; hence a significant number of diabetes patients may fall under the penumbra of the 'not to fast' advisory. We recognize that fasting is a personal choice and if a person chooses to fast despite advice to the contrary, he/she should be adequately supported and monitored closely during Ramadan and for a brief period thereafter. Current advancements in insulin delivery and glucose monitoring technologies are useful adjuncts to strategies for supporting type 1 diabetes patients considered to be high risk as well as 'high-risk' type 2 patients manage their diabetes during Ramadan. Although there is a lack of formal trial data, there is sufficient evidence across the different classes of therapeutic hypoglycaemic agents in terms of safety and efficacy to enable informed decision-making and provide a breadth of therapeutic options for the patient and the healthcare professional, even if the professional advice is to abstain. Thus, Ramadan provides an excellent opportunity for patient engagement to discuss important aspects of management, to improve control in the short term during Ramadan and to help the observants understand that the metabolic gains achieved during Ramadan are also sustainable in the other months of the year by maintaining a dietary and behavioural discipline. The application of this understanding can potentially prevent long-term complications.

Patient-guided modifications of oral anticoagulant drug intake during Ramadan fasting: a multicenter cross-sectional study

Fasting Ramadan is known to influence patients’ medication adherence. Data on patients’ behavior to oral anticoagulant (OAC) drug intake during Ramadan is missing. We aimed to determine patient-guided modifications of OAC medication regimen during Ramadan and to evaluate its consequences. A multicenter cross-sectional study conducted in Saudi Arabia. Data were collected shortly after Ramadan 2019. Participants were patients who fasted Ramadan and who were on long-term anticoagulation. Patient-guided medication changes during Ramadan in comparison to the regular intake schedule before Ramadan were recorded. Modification behavior was compared between twice daily (BID) and once daily (QD) treatment regimens. Rates of hospital admission during Ramadan were determined. We included 808 patients. During Ramadan, 53.1% modified their intake schedule (31.1% adjusted intake time, 13.2% skipped intakes, 2.2% took double dosing). A higher frequency of patient-guided modification was observed in patients on BID regimen compared to QD regimen. During Ramadan, 11.3% of patients were admitted to hospital. Patient-guided modification was a strong predictor for hospital admission. Patient-guided modification of OAC intake during Ramadan is common, particularly in patients on BID regimen. It increases the risk of hospital admission during Ramadan. Planning of OAC intake during Ramadan and patient education on the risk of low adherence are advisable.

A systematic review on the safety of Ramadan fasting in high-risk patients with Diabetes

INTRODUCTION

Fasting the holy month of Ramadan is passionately practiced by all Muslim population around the world. Patients with diabetes are generally considered to have a higher risk of fasting. The current international guidelines have risk-stratified the patients with diabetes and other comorbidities to different categories, and the decision of fasting or not is made based on this categorization. Many studies looked at the impact of Ramadan fasting on those high-risk patients, and many are currently being in progress.

METHODS

In this systematic review, we conducted an extensive search in PubMed and google scholar engines. Studies filtration focused only on the Randomized controlled trial (RCT) and prospective observational studies accomplished between the year 2007 up to March2019 on impact of Ramadan on patients with diabetes at high risk of fasting.

RESULTS

The global dissemination and implementation of the guidelines for the management of diabetes during Ramadan broke the inertia among health care providers. Additionally, the concept of pre-Ramadan assessment for risk categorization, therapeutic doses modification in hand with self -monitoring blood glucose; have markedly reduced the risk and hospitalisation during Ramadan.

CONCLUSIONS

There is still limited data on fasting Ramadan by high risk patients with diabetes. There was minimal diversity in the published results, however, Generally and despite the education, self-titration; the incidences of complications during Ramadan is minimally higher than other times of the year in this group.