Safer fasting during Ramadan

The fanoos (Arabic for lantern) is used as a decorative item during Ramadan.

A small pharmacy-led study has found that Muslims with type 2 diabetes can manage their blood sugar better during Ramadan in partnership with healthcare providers

The study, led by the National University of Singapore’s Department of Pharmacy and published in the Annals of Family Medicine, involved a tool called FAST, or “Fasting Algorithm for Singaporeans with Type 2 Diabetes”.

With FAST, Muslims with type 2 diabetes learn how to monitor and control their blood sugar level, so that they can fast safely during the Islamic holy month of fasting during daylight hours, and prayer.

It provides those who fast with Ramadan-specific education materials which includes guides on adjusting diet and lifestyle while fasting, as well as a medication dosage modification guide for patients and their doctors. 

“Muslims with diabetes are encouraged to actively monitor their blood glucose levels before, during and after fasting so that they can make informed decisions on their self-care such as making adjustments to their diet or doing light exercises,” said NUS Pharmacy doctoral student Lum Zheng Kang, who is the co-investigator of the study.

“Using FAST, they are also empowered to adjust the dosage of their diabetes medications based on its guidance and in close consultation with their doctors.”

The authors noted that while Islamic law exempts those who have conditions like diabetes from fasting, many people still fast because the practice “remains a deeply rooted sociocultural practice that provides spiritual enhancement and social cohesion among observant Muslims with type 2 diabetes”. Up to 94.2% reported fasting for at least 15 days during Ramadan.

The investigators evaluated the safety and effectiveness of FAST, which was developed in 2016, by conducting a randomised controlled trial that involved 97 fasting adults with type 2 diabetes in Singapore.

The study was carried out over two Ramadan cycles, in 2017 and 2018. The participants were divided into two groups: a group consisting of 46 patients who used FAST to guide their fasting and a control group of 51 patients who did not use FAST.

“A total of 97 participants were randomized (intervention: n=46, control: n=51),” the authors wrote.

“The HbA1c improvement during Ramadan was 4 times greater in the intervention group (−0.4%) than in the control group (−0.1%) (P = .049). The mean fasting blood glucose level decreased in the intervention group (−3.6 mg/dL) and increased in the control group (+20.9 mg/dL) (P = .034).

“The mean postprandial glucose level showed greater improvement in the intervention group (−16.4 mg/dL) compared to the control group (−2.3 mg/dL).

“There were more minor hypoglycemic events based on self-monitered blood glucose readings in the control group (intervention: 4, control: 6; P = .744). Glycemic variability was not significantly different between the two groups (P = .284). No between-group differences in diabetes distress were observed (P = .479).”

The authors noted that, “There were more confirmed incidents of actual minor hypoglycemia during Ramadan in the control group than the intervention group… This might have clinical implications because hypoglycemia events, whether minor or major, should be minimised to achieve optimal diabetes care.

“Interestingly, the present study had more unconfirmed self-reported minor hypoglycemia incidents among participants using the FAST tool (intervention: 13; control: 10).

“These findings suggested that the intervention participants were empowered with enhanced self-awareness of hypoglycemia management via the use of the FAST tool. The present study reaffirms the need for Ramadan-specific education to support individuals with the necessary knowledge and skills to recognize and manage hypoglycemia events for a safe fasting experience.”

They concluded that the findings emphasised the importance of efficacious, safe and culturally tailored epistemic tools for diabetes management.

“In Singapore, there is currently no religious and culturally tailored guide for people with diabetes to manage their condition when they fast during Ramadan,” said Mr Lum.

“It is important to address this challenge as these patients are at a higher health risk of severe hyperglycaemia (high blood sugar level) and severe hypoglycaemia when they fast during Ramadan. FAST is one of the first tools that addresses these gaps to help Muslims with diabetes to fast safely.”

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