Between Health and Faith - Managing Diabetes During Ramadan

A family is gathered in a home in Algiers, the capital of Algeria. In the living room several generations have come together, they have put on their finest clothes, they exchange loud cheers and big smiles. Music from a radio fills the room and the sound blends with the scents of green mint tea and fruit-flavoured juices. On the table are big copper trays full of delicacies such as dates stuffed with almond paste, rice pudding and honey-soaked pastries.

Malika Bouchayeb and her family are celebrating Eid al-Fitr which marks the end of the fasting month of Ramadan observed by millions of Muslims across the world as one of the five pillars of Islam. For the next couple of days they will be pampering their taste buds while celebrating the most important feast in the Muslim calendar. And with the variety of sugary dishes, it is no wonder that Eid is also sometimes referred to as ‘Sweet Eid’.

For Malika, this Eid is special. Malika has had type 2 diabetes since 2005 and although the Ramadan is supposed to be a month of spirituality and celebration, it has often been a time of distress for her because she has felt torn between her religion and her diabetes. When fasting, she had no energy and had a hard time controlling her blood sugar - fearing low blood sugar levels during the day as well as soaring high blood sugar levels when indulging in heavy meals after sunset. When she did not fast, she felt guilty not least because people around her questioned why she was not doing so. But this year she feels different.

No food, no water, no medication

Diabetes is a condition that requires careful management, blood sugar control, appropriate diet and for many also adherence to insulin. However, this is not exactly compatible with the tradition of fasting during the month of Ramadan where Muslims restrain from food, water and even medication from dawn to sunset. A widely quoted population-based study (EPIDIAR)¹ of diabetes and its characteristics during Ramadan covering 12,243 people in 13 countries, has shown that 43% of patients with type 1 diabetes and 79% of patients with type 2 diabetes fast during Ramadan. Coupled with a high global prevalence of diabetes, it is estimated that worldwide more than 50 million people with diabetes fast during Ramadan².

Despite the fact that the Quran makes exceptions for the sick, pregnant women, children and anyone for whom it would cause physical harm, many Muslims with diabetes insist on fasting and find it difficult not to due to social pressure and stigma. Also, they may experience conflicting messages from imams and healthcare professionals. So many of them embark on the month of fasting without seeking advice from a healthcare professional. But by doing so, they put themselves at risk, particularly those who are using insulin.

For people with diabetes fasting is associated with multiple complications such as severe dehydration, thrombosis and dangerously low blood sugar levels (hypoglycaemia). The EPIDIAR study found that the frequency of severe hypoglycaemic events is 4.7 higher in type 1 patients fasting during Ramadan compared to outside the Ramadan and 7.2 higher in type 2 patients. Paradoxically, excessively high blood sugar levels (hyperglycaemia) is also a problem during Ramadan because people tend to overeat when the fast is broken after sunset. And after the end of Ramadan patients often experience difficulties getting their blood sugar under control, too.

Balancing religious beliefs with medical needs

Algeria is an example of a country with a predominant Muslim population (99%) and a large number of people living with diabetes. According to the International Diabetes Federation, more than 1.6 million people in Algeria have diabetes³ and the majority of them are keen to fast during Ramadan.

“Managing diabetes during Ramadan is a big concern in our country. For many, religion is more important than their health and it is challenging to make people aware of the risks associated with fasting,” says Asma Sadeddine, project manager in Novo Nordisk Algeria.

Psycho-social issues often explain why people with diabetes fast during Ramadan although many are not supposed to according to medical recommendations. Often, individuals face strong pressures from family members, the community and their own conscience which has been highlighted in several studies⁴.

That is why many people with diabetes let their strong belief compromise their health, which was also the case for Malika. “There is a need to make both patients and healthcare professionals more familiar with the risks associated with fasting and to raise awareness among the general population, so that we can reduce the social stigma associated with not fasting,” says Asma. “But at the same time, we must also acknowledge that religious beliefs play an important role in people’s lives and take a culturally sensitive approach to how diabetes can best be managed during Ramadan.”

Partners and pragmatism

Novo Nordisk was the first pharmaceutical company in Algeria to decide that something had to be done to improve the situation for people with diabetes. For five consecutive years, they have now been working to raise awareness about this issue with the ‘Diabetes and Ramadan’ campaign. The campaign takes place two months before and during Ramadan and is carried out in collaboration with local stakeholders. According to Asma, who has been running the campaign for the past four years, a key strength of the campaign has been the involvement of partners representing both religious leaders, in the form of the Ministry of Religious Affairs, and the health community, including the National Diabetes Federation (FAAD), the National Society of Diabetes (SADIAB) and local diabetes associations.

Although it can be challenging to align messages among stakeholders with different perspectives, the partners have managed to take a pragmatic approach that both considers the religious context and the medical risks associated with fasting and they have agreed on formal guidelines that put the patient’s wellbeing at the centre.

One of the key objectives has been to encourage patients to consult with their doctor before taking a decision about fasting during Ramadan. The campaign has informed about the risks and provided specific recommendations on how to better handle their diabetes if they do choose to fast. Here, one concrete tool has been the development of an educational brochure, ‘Novopoche Diabetes and Ramadan’, which has been distributed widely via doctors, educational sessions and at awareness days organised for patients. In 2014, 8,600 patients were educated on how to manage their diabetes during Ramadan.

Another key activity of the campaign is to inform and train healthcare professionals to help them better support and advise their patients. This first and foremost includes general training in 1-day workshops where external experts speak about risks and recommendations when advising patients. In 2014, the campaign resulted in 90 paramedicals and 100 doctors being trained. In addition, Novo Nordisk has also developed material that includes advice on Ramadan to be used by medical representatives in their product promotion.

A catalyst for change

Each year activities are evaluated to help next year’s campaign. “It is important for us that we continue to refine our activities to increase impact,” says Asma. “For example, medical content of the campaign is updated based on the latest scientific evidence. And what was new this year was specific training sessions for diabetes nurses working in our educators’ local networks. This is a great way to expand outreach to patients.”

Looking back at five years with the ‘Diabetes and Ramadan’ campaign, Asma is happy to see the positive change that it has created. Not only has the campaign made a difference to the many patients and healthcare professionals who have participated in the training, but it is also increasing the general awareness about diabetes through media outreach which has helped decrease the social pressure put on people with diabetes and the stigma associated with not fasting. In addition, a clinical study is currently being carried out to better understand how medicine affects blood sugar levels and quality of life for people with type 2 diabetes during Ramadan with the aim to inform better and more tailored treatment.

And although the ‘Diabetes and Ramadan’ campaign has been customised for Algeria, it addresses a global issue which other countries with Muslim populations can benefit from. Asma is therefore engaged in sharing best practices with Novo Nordisk offices across the region as well as in Malaysia and India.

For Malika in Algiers, it is all about the local change. She is now able to make decisions about her fasting on more informed grounds after having discussed the issue with her doctor and participated in patient education. During Ramadan she monitors her blood glucose levels several times each day, she is careful about what she eats at the sunset meal and discontinues the fast if she needs to do so without feeling guilty. It means she can now enjoy this year’s Eid celebrations with an even bigger smile and without the bittersweet feeling of having had to compromise either her health or her faith.

Read the full issue of TBL Quarterly ‘Beyond Conflict: Putting the focus on health in the Middle East’.

---

1) Saltin et al. A Population-Based Study of Diabetes and Its Characteristics During the Fasting Month of Ramadan in 13 Countries. Diabetes Care, 2004; 27:2306–2311. Available at: http://care.diabetesjournals.org/content/27/10/2306.full.pdf

2) Al-Arouj et al. Recommendations for Management of Diabetes During Ramadan. Diabetes Care, 2010; Vol. 33, no. 8, August: 1895-1902. Available at: http://care.diabetesjournals.org/content/33/8/1895.long

3) International Diabetes Federation, Diabetes Atlas, 6th edition, 2013.

4) Patel et al. Having Diabetes and Having to Fast. Health Expectations, January 2014, Available at: http://onlinelibrary.wiley.com/doi/10.1111/hex.12163/abstract; Mygind et al. Patient perspectives on type 2 diabetes and medicine use during Ramadan among Pakistanis in Denmark. International Journal of Clinical Pharmacy 2013, Vol. 35, No. 2. Available from: http:// www.ncbi.nlm.nih.gov/pubmed/23354808; Ibrahim. Managing diabetes during Ramadan. Diabetes voice, June 2007, Vol. 52, issue 2. Available from: https://www.idf.org/sites/default/files/attachments/article_513_en.pdf