Joyce Yu-Chia Lee
During Ramadan, observant Muslims fast and forgo medications from sunrise to sunset for 1 month. Islamic law allows those with health conditions such as diabetes to avoid fasting, but data indicate not all of such Muslim patients accept the dispensation, according to research published in Annals of Family Medicine.
“Ramadan fasting remains a deeply rooted sociocultural practice that provides spiritual enhancement and social cohesion among observant Muslims with type 2 diabetes, with up to 94.2% reported to fast for at least 15 days during Ramadan,” Joyce Yu-Chia Lee, PharmD, BCPS, BCACP, a clinical pharmacist in the department of clinical pharmacy practice at the University of California, Irvine, and colleagues wrote.
Data have shown that this decision puts patients with diabetes at potential risk for complications, including hypoglycemia, hyperglycemia, dehydration, ketoacidosis and thrombosis, according to the researchers.
Other data highlight misconceptions about Ramadan among health care professionals. A survey published in the Journal of Primary Care and Community Health showed that only 38% of 45 primary care physicians and geriatric clinicians knew Ramadan tenets require abstinence from oral medications from predawn until after sunset. In addition, only 42% were aware of the food and fluid intake restrictions between sunset and dawn.
Reference: Lum ZK, et al. Ann Fam Med. 2020;doi:10.1370/afm.2500.
To reduce health risks and information gaps, Lee and colleagues developed the Fasting Algorithm for Singaporeans with Type 2 Diabetes, or FAST. The tool places emphasis on active clinician-patient engagement and empowerment of Muslims as informed decision-makers in their self-care management during Ramadan with self-monitoring of blood glucose and relevant medication adjustments, according to an article in Annals of Family Medicine.
Lee and colleagues evaluated the safety and efficacy of FAST in a study of 97 Muslims aged 21 years and older with diabetes who were randomly assigned to receive care with the tool (n = 46) or standard care (n = 51). Participants had baseline HbA1c levels of 9.5% or lower within 3 months before Ramadan and intended to fast for 10 or more days during the month.
Results showed that patients who used the FAST tool had a fourfold improvement in their HbA1c levels compared with patients who did not use the tool (–0.4% vs. –0.1%). Patients who used FAST also had decreases in their mean fasting blood glucose levels (–3.6 mg/dL vs. 20.9 mg/dL) and improvements in their postprandial glucose levels (–16.4 mg/dL vs. –2.3 mg/dL). The use of FAST tool also did not increase diabetes-related distress compared to the control.
Healio Primary Care spoke with Lee to learn more about how the tool works and how physicians can implement the tool in practice. – by Janel Miller
Q: Why was the FAST tool developed?
A: Current practice lacks culturally and religiously-tailored interventions. This empowerment-based collaborative algorithm (also known as FAST) was developed to meet the current practice gap in caring for this special population with type 2 diabetes who fast during Ramadan.
The International Diabetes Foundation’s Practical Guidelines for Diabetes and Ramadan published in 2016 were great initiatives that brought about more awareness on the management of diabetes during Ramadan. However, the duration of fasting hours can be shorter or longer depending on the geographic location of the Muslims around the world, and the difference in the types of foods consumed can also impact the outcome. Hence, we were not completely certain if the guidelines can be applied to Muslim-minority countries such as Singapore.
In addition, patients who observe Ramadan devote their time and focus to praying, and it is unlikely that they would want to visit a health care clinic during this period. They may not even have easy access to a health care provider whose clinic hours will align to their religious needs. This also prompted us to come up with an algorithm that allows us to teach our own patients to adjust their antidiabetic medications when their glucose readings are out of target.
Q: How does the algorithm work?
A: FAST is a stepwise clinical decision-making tool that consists of: risk-assessment screening; Ramadan-specific patient education with self-monitoring of blood glucose; structured glucose-lowering medication modification guidance for health care clinicians, and 4) self-dose adjustment guidance based on self-monitoring of blood glucose readings during Ramadan for patients. Health care professionals are guided to identify patients who are eligible to fast and given recommendations to adjust the antidiabetic medications as appropriate. Patients are then taught to modify their medications accordingly using readings from their self-monitoring of blood glucose levels. Upon completion of fasting, patients should revert back to pre-Ramadan regimen and attend a follow up appointment with their providers.
Q: How was the algorithm developed?
A: The algorithm stemmed from two studies that were published in 2014 and 2015. In the 2014 prospective study of 153 patients, we found that fasting during Ramadan indeed improved glycemia of patients with type 2 diabetes, especially in those whose medications were adjusted in anticipation of fasting. The 2015 study examined the metabolic parameters of 5172 patients with type 2 diabetes using Singapore’s National Electronic Database. In this study, we also found fasting related improvement in blood glucose but insignificant changes in blood pressure or lipid profiles. These outcomes including the medication dosing patterns observed in these studies with reference to the 2016 International Diabetes Foundation Practical Guidelines for Diabetes and Ramadan were used to draft the algorithm, and it was then discussed among panels of clinicians which included endocrinologists, family physicians, diabetes nurse educators and clinical pharmacists who have had experience managing patients with type 2 diabetes who fast during Ramadan. The algorithm was piloted for its user-friendliness among providers and patients before it was finally implemented in the clinical trial.
Q: How can physicians implement this tool in practice?
A: In our studies, we saw the challenges of patients being scared to share information with their health care providers, mainly because they were worried that their providers would tell them not to fast or that they would not understand their religious beliefs Therefore, coordination of care is very important. The entire health care team in the clinic needs to be aware of this particular algorithm, have basic knowledge of Ramadan, identify patients who commemorate the holiday and talk to these patients about it. Health care providers can work collaboratively and involve or refer to pharmacists for in-depth counseling on medication use during fasting. This tool is not just a way of trying to help patients fast, safely and effectively. It is also as an incentive for them to continue to stay well, so that they will continue to be eligible for this particular algorithm. [Editor’s note: The full algorithm can be found here.]
Ahmed MH, et al. J Family Med Prim Care. 2017;doi:10.4103/2249-4863.214964.
Ali M, et al. J Prim Care Community Health. 2016:doi:10.1177/2150131915601359.
Lum ZK, et al. Ann Fam Med. 2020;doi:10.1370/afm.2500.
Disclosure: Lee reports no relevant financial disclosures.