Ramadan with diabetes: pharmacists need training

"diabetes" in coloured text

Pharmacists need more resources on how to help patients whose cultural and religious practices may impact on chronic illness, a new study looking at patients with diabetes who fast during Ramadan has found.

The study, Pharmacists’ perspectives about their role in care of patients with diabetes observing Ramadan, examined how pharmacists approach professional services for patients with Type 2 diabetes who may observe the Ramadan fast.

Ramadan is the ninth month of the Muslim calendar, which sees Muslims who observe the fast of Ramadan abstain from all food and drink during daylight hours. In 2016 it will commence on Tuesday, June 7.

The study involved 21 semi-structured interviews with pharmacists in Western Sydney, and found that there were barriers to helping these patients manage their diabetes during the month.

“Although most participants encountered fasting patients, and were willing to engage in diabetes services for them, our analyses indicated reactive counselling, lack of perceived need for counselling patients or delegation of patient care in a few instances as well as organisational issues as a practice barrier,” the authors wrote.

“The absolute abstaining of food and drink between sunrise and sunset makes homeostatic disruption likely,” they say. “Fasting may influence the body’s homeostatic rhythms, and in those taking chronic medications, fasting may upset established pharmacokinetic and pharmacodynamic disposition patterns of medications.”

Study co-author Hadi Almansour told the AJP that certain groups of people are exempt from fasting during Ramadan, but in practice many are still keen to attempt the fast.

“There are some exemptions, such as pregnant women and people with Type 1 and Type 2 diabetes and some other diseases, and they will often discuss this reason with their spiritual advisors,” he says.

“But some people will say, ‘I’ll do my best to fast’ even though they may not have to, and some patients don’t listen to advice from health care professionals about it.”

The practice of fasting despite having diabetes has been reported and observed in many countries, the study says, for reasons including a reluctance to feel isolated from cultural and religious groups in a religious event of significance.

For this reason privacy is a significant issue, as some Muslims who are not fasting are unwilling to discuss the matter in a retail setting.

“They know that it’s a community and everybody knows each other here, so they’re inclined not to speak in front of other people if they don’t want to fast,” one pharmacist quoted in the paper said.

“So it is a bit of a deterrent to them… the people who are really sensitive about it, they just don’t want to talk.”


The study found that:

  • Many patients self-adjusted their medication regimens, in some cases inappropriately; this included strategies such as skipping a midday dose.
  • Some patients did seek information about their medication regimens, but most did not.
  • Some pharmacists believed their patients did not seek information on the subject as they feared they would simply be encouraged not to fast.
  • Some pharmacists indeed made this recommendation.
  • Most participants said counselling occurred only if they asked for help.


Almansour told the AJP that both patients and pharmacists could significantly benefit from improved communication, including letting patients know of the availability of professional services.

“We could be raising awareness to patients that pharmacists can do such things, for example at community centres and maybe mosques,” he says.

He also suggests that pharmacist students and interns be given improved training, including case studies, on the subject. This included cultural sensitivity training.

“Some of the pharmacist participants didn’t really understand the importance of fasting to religious people,” he says.

“We also found that some of the pharmacists were waiting for the patient to ask questions, but they should be initiating these conversations rather than waiting for questions to be asked.

“Once they know a regular customer, they can ask, ‘How are you going with your diabetes medication?’ because often a pharmacist will get to know that a regular customer will be fasting during Ramadan.

“Pharmacists have the communication skills to ask these questions, and provide answers.”

The study concluded that pharmacists need educational/awareness resources to enhance their cultural and clinical competency, and that patient information materials are needed in the case of patients opting to fast during Ramadan.

It highlighted the potential for non-dispensing pharmacists in GP surgeries to help optimise outcomes for these patients, including the ‘Ramadan Education and Awareness in Diabetes (READ)’ program in the UK which educated patients with Type 2 diabetes who planned to fast on meal planning, physical activity, glucose monitoring, hypoglycaemia, dosage and timing of medications.

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  1. Richard Lord

    This is a very pertinent and well thought out article. It did worry me as a pharmacist working in the Maldives that Muslims on medication did not eat or drink water during the day.
    Thanks for including the article
    Rick Lord

  2. Karalyn Huxhagen

    excellent work. I have encountered this issue in the community and HMRs . Many patients do not broach the issue with their pharmacist as they are concerned we will say do not fast. A work around needs to be found for each patient. I encounter the same issue with shift workers. What is breakfast to them varies a lot so adjusting medication can be difficult based on their shifts.

    Cultural educational and cultural safety in undergraduate and post graduate has been a need for many years.

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