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When should a diabetic patient end the fast immediately?

a) When the hypoglycemic symptoms appears. (Refer symptoms of hypoglycemia -1st page )
b) If the patient monitors the blood glucose and notice hypoglycemia ( <3.5 mmol/l )
c) If glucose reaches <3.9mmol/l in the first few hours after the start of fast especially if insulin, sulphonylurea has been taken at pre dawn.
d) If glucose > 16mmol/l ( hyperglycemia )

Advise on breaking the fast in Ramadan
Diet during Ramadan should not differ significantly from a healthy and balanced diet. Instead it should aim at maintaining a constant body mass. In most studies, 50–60% of individuals who fast maintain their body weight during the month, while 20–25% either gain or lose weight; occasionally, the weight loss may be excessive (>3 kg). It is not advisable to consume large amounts of foods rich in carbohydrate and fat, especially at the sunset meal. Predawn meal may include foods containing “complex” carbohydrate, while foods with more simple carbohydrates may be more appropriate at the sunset meal. Such allocation is made in view of the delay in digestion and absorption.

Should patients stop carrying out physical exercise during fasting month?
Excessive physical activity may lead to higher risk of hypoglycemia and should be avoided, particularly during the few hours before the sunset meal. However, normal level of physical activities may still be carried out. If Tarawaih prayer (multiple prayers after the sunset meal) is performed, then it should be considered a part of the daily exercise program. In certain patients with poorly controlled type 1 diabetes, exercise may lead to severe hyperglycemia.

Conclusion
Clearly there are many issues to be addressed to patients on the management of diabetes during Ramadan. When patients fail to adhere to the oral hypoglycemic agent or insulin regime in the past 11 months, chances are they may at risk to develop complications of diabetes if at all they choose to fast.

Diabetes is more than just high blood glucose but it is a complex metabolic disorder affecting multi organs and small vessels as well. Drugs and Insulin are just part of the management of diabetes as it requires much self discipline and lifestyle modification for the better control of blood glucose.

Patients and health care providers should look beyond the numbers appear on the gluco meter but to associate these numbers with the co-morbid conditions (like heart diseases, renal insufficiency, stroke) to stratify the risk of diabetes associated complications.

Management of diabetes also call for support from patients and family members as doctors as well as health care providers are not able to make much difference if no cooperation from all as a team. For that matter, there are many NGOs are being set up to help diabetic patients to support each other and share the knowledge on living with diabetes.

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Dr. Sloan, MD., is a qualified practicing medical doctor with a passion for the promotion of a healthy lifestyle and the prevention of illnesses and diseases. Subscribe for his newsletter containing solid information and advice at http://www.drsloanmd.com.
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Technorati Tags: break fast, Diabetes, diabetic condition, diabetic patients, diet, stop fast

All diabetic patients should know the symptoms of hypoglycemia which include :
a) Shaking, tremor
b) Sweating
c) Anxious
d) Dizziness
e) Hunger
f) Fast Heartbeat / palpitation
g) Impaired vision
h) Fatigue / Weakness
i) Headache, poor concentration
j) Irritable

There is significant increased risk associated with fasting among diabetic patients. ( Reference: DiabetesCare ,America Diabetes Association, ADA)
a) Severe Hypoglycemia :- EPIDIAR study showed that fasting during Ramadan increased the risk of severe hypoglycemia (defined as hospitalization due to hypoglycemia) as 4.7-fold from 3 to 14 events/100 people /month in type 1 diabetes while 7.5-fold in patients with type 2 diabetes from 0.4 to 3 events/100 people / month.
b) Hyperglycemia:-. The extensive EPIDIAR study showed a x5 fold increase in the incidence of severe hyperglycemia (requiring hospitalization) during Ramadan in patients with type 2 diabetes (from 1 to 5 events /100 people / month) and an approximate x3 fold increase in the incidence of severe hyperglycemia with or without ketoacidosis in patients with type 1 diabetes (from 5 to 17 events/100 people/ month) .Hyperglycemia may have been due to excessive reduction in dosages of medications to prevent hypoglycemia. Patients who reported an increase in food and/or sugar intake had significantly higher rates of severe hyperglycemia .
c) Diabetic Ketoacidosis:- Patients with diabetes, especially those with type 1 diabetes, who fast during Ramadan are at increased risk for development of diabetic ketoacidosis, particularly if they are grossly hyperglycemic before Ramadan. In addition, 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.
d) Dehydration and Thrombosis:- As a result of limitation of fluid intake during the fast, especially if prolonged may lead to dehydration which can be severe in hot and humid climates and electrolyte depletion. Orthostatic hypotension may develop, especially in among individuals who perform hard physical labor, all conditions that result in excessive perspiration. In addition, hyperglycemia can result in osmotic diuresis and contribute to volume patients with preexisting autonomic neuropathy. Syncope, falls, injuries, and bone fractures may result from hypovolemia and the associated hypotension. In addition, contraction of the intravascular space can contribute to a hypercoagulable state.

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Dr. Sloan, MD., is a qualified practicing medical doctor with a passion for the promotion of a healthy lifestyle and the prevention of illnesses and diseases. Subscribe for his newsletter containing solid information and advice at http://www.drsloanmd.com.
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Technorati Tags: Diabetes, diabetes ketoacidosis, diabetic patients, fasting, hyperglycemia, hypoglycemia, ramadan

“Medical advice is sometimes ignored for religious reasons. Occasionally a devoted Muslim will say, ‘Allah will protect me’. He or she may not fear death or may even want to die so as to meet the Creator. Counsel the patient by saying ‘to see the doctor and comply with treatment is Prophet Mohammad’s sunnat (precedent)’. To refuse would be a sin.” JRSM (Journal of Royal Society of Medicine)

It is important to inform the Muslim patients that it is not a sin to skip the fast if they are found to have medical problems. Most of the doctors would advise the following patients to avoid fasting:
1) Acute Peptic Ulcer
2) Pulmonary Tuberculosis
3) Bronchial Asthma
4) Cancer
5) Diabetes –Type 1 and 2
who have poor glycemic control (HbA1c >12%), non compliant with diet or drug/oral regimes, four OR more episodes of hypoglycemia AND/OR hyperglycemia during preceding month, on 2 and MORE insulin injection/day.
6) Urinary Calculi
7) Cardiovascular disease
Psychiatry
9) Liver disorder, hepatic dysfunction where the liver enzyme is >> 2 x Upper Normal Limit.
10) Pregnancy

————————————————————————
Dr. Sloan, MD., is a qualified practicing medical doctor with a passion for the promotion of a healthy lifestyle and the prevention of illnesses and diseases. Subscribe for his newsletter containing solid information and advice at http://www.drsloanmd.com.
========================================

Technorati Tags: Diabetes, diabetic patients, medical contraindications, Ramadan fasting