Fasting for diabetics is risky, says expert
30 July, 2012
KARACHI: Since many patients with diabetes, who are otherwise unfit, insist on fasting during Ramazan, thereby creating a medical challenge for themselves and their physicians, says National Institute of Diabetes & Endocrinology, Dow University of Health Sciences, in a public awareness programme organised recently.
“Fasting, especially among patients with Type 1 diabetes with poor glycemic control, is associated with multiple risks,” Director of the Institute, Prof M Zaman Shaikh, said in his lecture. He discussed some of the complications occurring in diabetic patients during Ramazan, which are as follows:
Hypoglycemia (very low blood sugar): Fasting during Ramazan increases the risk of severe hypoglycemia (defined as hospitalisation due to very low blood sugar), 4-7 fold increase in patients with diabetes, depending on the types and degree of severity and control of diabetes.
Hyperglycemia (very high blood sugar): There is a five-fold increase in the incidence of severe hyperglycemia (requiring hospitalisation) during Ramazan in patients with Yype 2 diabetes and approximate three-fold increase in the incidence of severe hyperglycemia with or without ketoacidosis in patients with Type 1 diabetes.
Diabetic ketoacidosis coma: Patients with diabetes, especially those with Type 1 diabetes, who fast during Ramazan, are at increased risk for development of unconsciousness due to diabetic ketoacidosis, particularly if they are grossly hyperglycemic before Ramazan. The risk for diabetic ketoacidosis may be further increased due to excessive reduction of insulin dosages based on the assumption that food intake is reduced during the month.
Dehydration and thrombosis: Limitation of fluid intake during the fast, especially if prolonged, is a cause of dehydration. The dehydration may become severe in hot and humid climates and among individuals who perform hard physical labour, all conditions that result in excessive perspiration. In addition, hyperglycemia can result in diuresis (excessive urination) and contribute to volume and electrolyte depletion. Syncope, falls, injuries, and bone fractures may result from hypervolemia and the associated low blood pressure. Increased blood viscosity secondary to dehydration may enhance the risk of thrombosis.
In EPIDIAR (Epidemiology of Diabetes and Ramazan – 1422/2001) Study which was done in 13 Islamic countries, out of 12,243 people with diabetes, 43 percent of patients with Type 1 diabetes and 79 percent of patients with Type-2 diabetes were keeping fast during Ramazan. Frequency of acute complications was higher in them.
General considerations: Frequent monitoring of glycaemia: It is essential that patients have the means to monitor their blood glucose levels multiple times daily. This is especially critical in patients with Type 1 diabetes and in patients with Type 2 diabetes who require insulin.
Nutrition: To remain healthy, a diabetic person must eat from all the major food groups. The quantity of food consumed should be less than the routine days. The fruit consumption should be increased, but not in form of juices and milk shakes. Take sufficient amount of water between Iftar and Sehr to avoid dehydration. Take enough quantity of vegetables. Try to avoid spicy and very salty food. Stay away from caffeine, including tea, coffee and colas. Stay away from oily and fried things like pakoras and samosas.
About 50–60 percent of individuals who fast maintain their body weight during the month, while 20–25 percent either gain or lose weight, occasionally, the weight loss may be excessive - more than three kilogrammes. The common practice of ingesting large amounts of foods rich in carbohydrate and fat, especially at the Iftar time, should be avoided.
Exercise: Normal levels of physical activity may be maintained. However, excessive physical activity may lead to higher risk of hypoglycemia and dehydration and therefore should be avoided during daytime.
Ending the fast: All patients should understand that they must always and immediately end their fast if hypoglycemia (blood glucose of less than 60 mg/dl occurs, since there is no guarantee that their blood glucose will not drop further if they wait or delay treatment). Finally, the fast should be broken if blood glucose exceeds 300 mg/dl. Patients with Type 1 diabetes, especially if ‘brittle’ or poorly controlled, are at very high risk of developing severe complications and should be strongly advised to not fast during Ramazan. In addition, patients who are unwilling or unable to monitor their blood glucose levels multiple times daily are at high risk and should be advised not to fast.
Management of patients with Type 2 diabetes: Diet-controlled patients :In patients with Type 2 diabetes who are well controlled with diet alone, the risk associated with fasting is quite low. They should be encouraged to keep fast.
Patients treated with oral agents: They may also keep fast however they should take higher dose of tablets at the time of Iftari and lower dose at the time of Sehri. Some oral drugs are comparatively safer during fasting. Patients should seek advice from their doctors regarding changing the dose and type of tablets.
Patients using insulin: Patients on single dose of insulin in 24 hours may keep fast. However it is risky for patients to keep fast who are on more than two doses of insulin in a day. Again some insulin are safer during Ramazan, they are usually short-acting, analogue type of insulin.
Management of hypertension and dyslipidemia: High blood pressure and high cholesterol should be taken care of during Ramazan. Because due to dehydration, there is tendency of low blood pressure and because of high intake of traditional food items at Sehri and Iftar like samosa, rolls, pakoras, khajla, sweet dahi bara, there is tendency of high cholesterol.
Patients with Type 1 diabetes who have a history of recurrent hypoglycemia or hypoglycemia unawareness or who are poorly controlled are at very high risk for developing severe hypoglycemia. In general, these patients with Type 1 diabetes should be strongly advised not to fast.
The management plan of diabetic patients keeping fast must be highly individualised.
On this occasion, Pro M Zaman Shaikh announced opening of ‘Thyroid Clinic,’ at National Institute of Diabetes and Endocrinology, Ojha Campus, that will run on regular basis at the institute on every Tuesday, for the patients with all thyroid disorders.