PROFESSOR M H CASSIMJEECHIEF SPECIALIST

HEAD : DEPARTMENT OF FAMILY MEDICINEP M BURG METROPOLITAN COMPLEX AND MIDLANDS REGION

FASTINGLong and rich History

Mahatma Gandhi - Political EffectWest – Slimming FadsReligious Rituals by many faith groups

Judaism- Yomkippur FastEastern Christian Sects – Lent FastHinduism – Puratassi/NavarathriMuslims - Ramdaan Fast

RAMADAN FASTING

Involves 1 in 6 of all humans and is the most widely observed celebration of this most scared of rituals.

SIGNIFICANCE OF RAMADAN AND HOW CLOSE FASTING IS TO THE

MUSLIM INDIVIDUAL

A blessed monthRamadan – 9th Month of Islamic CalendarHoly Quran was revealed to Prophet Muhammed (PBUH), 14 Centuries agoRamadan marks the unfolding of a Familiarbut Distinct Chapter in Religious History

THE FAST

Familiar in that the message is a re-affirmation and re-articulation of that delivered by Abraham, Moses, David, John the Bapist and Christ.

Distinct - for this marked Allah’s Final Reminder through his final Emissary Prophet Muhammad (PBUH) to ‘ALL THE WORLDS’

THE FAST

Prophet Muhammad (PBUH) taught that not only are good acts magnified innumerably during the month of Ramadan, but a gate of paradise is dedicated to the Fasting.

For the Man and the Woman in the street the, Ramadan is synonymous with Blessing.

RAMADAN MOON

Ramadan is the ninth lunar month and one of the four pillars of Islam

THE HOLY QURAN

[97:0] In the name of God, Most Gracious, Most Merciful

THE NIGHT OF DESTINYTHE POWER OF THE NIGHT

THE NIGHT OF DESTINYTHE POWER OF THE NIGHT

• [97:0] In the name of God, Most Gracious, Most Merciful 1.

[97:1] We revealed it in the Night of Destiny.* *97:1 The Quran was placed into Muhammad's soul on the 27th night of Ramadan, 13 B.H. (Before Hijrah). See

also 17:1, 44:3, 53:1-18, and Appendix 28.

• 2. [97:2] How awesome is the Night of Destiny!

• 3. [97:3] The Night of Destiny is betterthan a thousand months.

• 4. [97:4] The angels and the Spirit descendtherein, by their Lord's leave, to carryout every command.

• 5. [97:5] Peaceful it is until the advent of the dawn.

FROM SAHIH AL-BUKHARI VOLUME Ill.

Narrated Abu Huraira from the Prophet1 & "Whoever did not fast for one day of Ramadan without

genuine excuse or a disease, then even if he fasted for a complete year, it would not compensate for that day." The same is narrated from Ibn Mas'ud.

Sa'id bin AI-Musalyab, Atth-S_ha'bi, Ibn Jubair, Ibrihim, Qatada and I;tammad said, "He (a fasting person) should fast one day In lieu of that missed fast."

THE FASTFASTING IS AN OBLIGATION ON EVERY RESPONSIBLE AND HEALTHY MUSLIM, MALEAND FEMALE.THOSE EXEMPT FROM FASTING :

Children under the age of pubertyThose with learning difficulties or retardation such that they are unable to comprehend the nature and purpose of the fast

EXEMPT FROM FASTING

The acutely unwellThe old and frailThose with chronic illness, in whom fasting may be detrimental to healthTravellers who are journeying greater than approximately 50 milesMenstruating, pregnant and nursing women

CONSENSUS FROM 3 INTERNATIONAL MEETINGS ON

FASTING

TYPE 1 DIABETIC- Do not have to fast- Danger of Hypoglycaemia/Ketoacidosis- If insistent on fasting require very careful

supervision if on Basal Bolus. (Someone experienced and knowledgable in Diabetes Management.)

CONSENSUS FROM 3 INTERNATIONAL MEETINGS

ON FASTING

TYPE I Diabetic- Evening Insulin Dose - Normal (Iftar)- Morning Insulin Dose - ± 50% of

normal requirements (Sehri)- At bed time <50% of Long Acting

Insulin (Protophane/Lantus (Aventis) Clear 24 hours peakless insulin

AIMS OF MANAGEMENT

Do not go for tight control8-9 mmol/l is acceptableAim for control which will keep the patient out of trouble ie. Hypoglycaemia/Ketoacidoses

CONSENSUS FROM 3 INTERNATIONAL MEETINGS

ON FASTING

TYPE II DIABETES• If doing well on diet control no

problem – okay to fast• If on Metformin – no problem

Metformin is anti-glycaemic and not Hypoglycaemic

CONSENSUS FROM 3 INTERNATIONAL MEETINGS ON

FASTING

If on SulfonylureasReverse day/night dosagesTake usual morning dose after Iftar (supper) and reduce dose to possibly ½ at Sehri (early morning meal)

CONSENSUS FROM 3 INTERNATIONAL MEETINGS

ON FASTING

If on both Daonil and MetforminRecommended

Take Daonil and Metformin in usual dose after Iftar (Evening Meal)Leave out Daonil at Sheri (early morning meal), take only MetforminHowever if midday sugar levels are ↑introduce Daonil in small dose at Sehri time (Early morning meal)

CONSENSUS FROM 3 INTERNATIONAL MEETINGS

ON FASTINGIf Type II Diabetes is on Insulin Therapy.If on Basal Bolus – Manage same as for Type I Diabetic

- Evening insulin dose normal (Iftar)- Insulin Dose - ± 50% of normal requirements (Sehri)- At bed time <50% of Long Acting Insulin (Protophane/Lantus

(Aventis) Clear 24 hours peakless insulin

CONSENSUS FROM 3 INTERNATIONAL MEETINGS ON

FASTING

Type II Diabetes if on Bi-Phasic InsulinTake usual breakfast dose at Iftar (Evening Meal)Reduce Sehri dose (early morning meal) to 50% of usual evening dose

PATIENTS HAVE TO BE INDIVIDUALISED

CONSENSUS FROM 3 INTERNATIONAL MEETINGS ON

FASTINGIf on Bi-Phasic insulin + Metformin Give Iftar (evening dose) as same as for normal breakfast butTake Metformin at Sehri (early morning meal) and patient may be okay and not require ActraphaneBut if midday blood sugar control not good, reduce Actraphane to 50% of normal evening dose at Sehri (early morning meal)

SOME EXAMPLES OF DIABETIC MEDICATION

ORAL MEDICATION-Metformin : Immediately after meals

Preferable to take film coated tablet. Minimises side effects.

ANTIGLYCAEMIC NOT HYPOGLYCAEMIC

SOME EXAMPLES OF DIABETIC MEDICATION

Sulphonylureas : Secretagogues.If on Glibenclamide, think about changing to quick-acting sulphonlurea (eg. Glipizide) for duration of fast, to be taken once a day before the break of fast meal.

SOME EXAMPLES OF DIABETIC MEDICATION

Prandial regulatorsRepaglinide may be particularly useful for fasting because of its short action and it can be taken when eating and not taken when fasting. This has been shown to help with glycaemic control during Ramadan compared with sulphonlureas.Research : Diabetic control does not deteriorate in Ramadan.

SOME EXAMPLES OF DIABETIC MEDICATION

Glitazones (Rosiglitazone and Proglitazone)Increases insulin sensitivity hence sensitizers. The dosage of these taken without other medications should not be affected if taken with or without food at the same time each day unless the overall calorie and fat intake content is lower.

SOME EXAMPLES OF DIABETIC MEDICATION

o Biphasic InsulinNovomix 30Humalog 25 immediately before mealsHumalin 30/70

o Short Acting Insulins 3 x day• Humalog

or• Novorapid

SOME EXAMPLES OF DIABETIC MEDICATION

At Bed Time-Long acting Insulin eg. Lantus (Aventis) (for young)-This is a clear 24 hour peakless insulin

– steady state

SUMMARY OF RECOMMENDATIONS FOR DIABETIC PATIENTS WISHING

TO FAST

Diet ControlMake the pre-dawn meal the major meal of the daySpace meals equally over the non-fasting period

On Sulphonylureas- If on a single daily dose, take medication with

the sunset meal- For those on more than a once –daily regimen

switch the morning dose (plus any midday dose) with that taken at sunset

SUMMARY OF RECOMMENDATIONS FOR DIABETIC PATIENTS WISHING

TO FAST

On Insulin- Fasting is not recommended in those prone

to keto-acidosis or with wide swings in blood glucose

- If on a single dose, change to a twice –daily regimen

- For those on a twice-daily regimen, take half or one third of insulin dose in the morning and take the usual evening dose

CORE ISSUES IN COUNCELLING DIABETICS PATIENTS WHO WISH

TO FAST IN RAMADAN

Do not aim for optimal control ie. Not for tight control.Maintain control to allow patient to stay out of trouble (ie. Hypoglycaemia/KetoacidosesEngage in a practice run during Shabaan Fast. (like preparing for Comrades).

CORE ISSUES IN COUNCELLING DIABETICS PATIENTS WHO WISH

TO FAST IN RAMADAN

The moment patient is in trouble (eg Blood Sugar 2.4 mmol/l at 3.00pm) do not bide for time –must break fast immediately since heroic acts of misplaced piety have nothing to do with the teachings of Islam.

WHEN YOU WERE BORN, EVERYONE WAS SMILING, BUT YOU WERE CRYING.

LIVE SUCH A LIFE THAT WHEN YOU DEPART, EVERYONE IS WEEPING BUT YOU ARE SMILING

Sa’di of Shiraz (d. 1292)

ABSOULTE CONTRA-INDICATION TO FASTING

Young Type IUnless supervised on a one to one bases by

Doctorexperienced in managing diabetes.