Abstract
Successful completion of Ramadan Is a great achievement for believers and provides spiritual merit. Helping others in their achievement is equally meritorious. Through its chapters, this book tries to facilitate the observance of healthy Ramadan fasting, for millions of Islamic adherents with diabetes. This book is a sincere attempt to solve this paradoxical challenge for diabetes care professionals who have to manage diabetics observing the Ramadan fast. It provides practical guidance regarding various aspects of diabetes management during the holy month.
HEALTH
“The most beloved by Allah of things He is asked to grant is (Al-aafiyah) good health” (Tirmidi).
Health is a state of a life that all living beings aim for: A condition of complete physical, mental and social well-being, and not merely the absence of disease or infirmity.1 As physicians, we are privileged to be able to help our fellow human beings try and achieve this state.
At times, however, our treatments and cures may end up being worse than the disease or disorder itself. This sometimes happens because of side effects or adverse reactions to our drugs. More often than not, however, patients complain of a high index of intrusion of treatment. This is especially true for people with diabetes, who have to deal with this chronic condition on long-term basis.
INTRUSION IN HEALTH
Intrusion of treatment, in this context, means a forced change in one's routine lifestyle, caused by a particular management strategy. For example, being asked to take six meals a day may be considered as intrusion by a person habituated to two major 4meals. Another example of intrusion can be a prescription for injectable therapy, or for frequent glucose monitoring, which conflicts with strongly held religious or cultural beliefs.
The intrusion of diabetes, and diabetes therapy, into one's lifestyle, becomes more pronounced in societies with a strong sociocultural ethos. Such communities, in general, tend to observe religious and cultural events, such as fasts and feasts, with great enthusiasm and public participation.
RAMADAN
“O ye who believe! Fasting is prescribed to you as it was prescribed to those before you, that ye may (Learn) self-restraint,” (Al-Quran 2:183).
One such observance is Ramadan, the holy month of fasting, ordained as one of the five central pillars of Islam. Followed by billions of adherents, spread across all continents, the Ramadan fast provides spiritual upliftment and wellbeing to people who practice the Islamic faith.2 Keeping the Ramadan fast, however, poses physical challenges to all persons. These challenges are magnified in persons with diabetes, whose metabolic milieu may not be geared to prolonged fasting.
Apart from the physical stress associated with fasting, however, people with diabetes also face psychological and social obstacles during Ramadan. The overlap of Ramadan and diabetes, in fact, becomes a perfect case for the study of the biopsychosocial model of health, so elegantly coined by Unger in 1977.3
BIOPSYCHOSOCIAL MODEL
The biopsychosocial model was created to explain the various nonbiological determinants which impact health.3
This model has stimulated debate about health and disease, and has been utilized not only in psychiatry, but also in chronic disease such as diabetes.4 The biopsychosocial model is required for an indepth understanding of the Islamic person's perspective on Ramadan. One of the important aspects of any individual, while defining health, “is the need to’ be normal,” “feel normal,” and “appear normal”. The concept of “appearing normal” becomes even more important in close knit societies, where premium is laid on homogeneity rather than exceptions.
In Ramadan, when social contacts between friends and family increase, the need to “appear normal” increases. For the person with diabetes, normalcy includes the ability to observe the holy fast, join in group prayers, and take part in festival meals.
PERSON CENTERED CARE
The person-oriented nature of the preceding statements is verbalized in the supposedly modern concept of patient centered care.5 Islamic theology, however, unequivocally promotes a robust patient centered philosophy.6 Numerous verses from the Holy Quran, and evidence from the Hadiths, speak for this.
THE ROLE OF THE PHYSICIAN
The physician plays an important role in achieving the desired definition of health. In the context of Ramadan, this is easier said than done. Creating concordance between biological demands of the body (insulin requirement) and pharmacokinetic properties of prescribed medication becomes a challenge, as rigid dietary and physical activity patterns have to be followed.
The traditional model of medical care entails patient acceptance of physician-defined regimes without much consideration for patient lifestyles and habits. While this approach to diabetes care may have its benefits, it does not work in Ramadan.
The rules of Ramadan fasting, which been ordained to promote self-restraint and self-discipline amongst devout believers must be respected. Even though Islam provides for exemption from fasting on medical grounds, many people prefer to fast, to achieve spiritual gain.7 The preference for religious fasting at the cost of metabolic disturbance, is the patient's decision. While one can debate the degree to which patient empowerment should be encouraged.8 Ramadan offers a special challenge. Not allowing people to fast may lead to psychological stress and/or social stress, which by themselves may lead to poor glycemic control. This fact has to be balanced with the potential disturbance in glycemia that can be caused by fasting.
As long as the patient's life, organs or limbs are not put at risk, religious fasting should be allowed for people with diabetes. It is the physician's duty to ensure the person with diabetes receives appropriate pre-Ramadan counseling,9 and proper adjustment of glucose lowering drugs.
This can be achieved by a planned and systematic approach, involving patient education, patient empowerment and shared decision making.
NEWER DRUGS AND TECHNOLOGIES: THE KNOWLEDGE PARADOX
The advent of newer drugs, devices and technologies, over the past decades has revolutionized diabetes praxis. Paradoxically, this has made diabetes care simpler, as well as more complex, both for diabetes care professionals and for people with diabetes. This paradox holds true for Ramadan as well. The availability of designer molecules, both oral and injectable, with less risk of hypoglycemia, makes it easier for devout believers to observe the Ramadan fast. Long-acting drugs, requiring lesser frequency of administration, are suited for the dietary patterns that the Ramadan fast demands.10 At the same time, the sheer number of antidiabetic drugs, and the permutations and combinations in which they can be used, present a challenge to the physician. Utilization of all available therapeutic modalities, in optimal, based either on evidence, or on logical empiricism,11 needs constant upgradation of knowledge.
Narrated by Usamah Bin Shareek (may Allah be pleased with him): ‘I was with the Prophet (PBUH) and some Arabs came to him asking “O messenger of Allah, should we take medicines for any disease?” He said, “Yes, o you servants of Allah take medicine as Allah has not created a disease without creating a cure except for one”. They asked which one, he replied “old age”.
THE FLOW OF THIS BOOK
This book hopes to solve this paradoxical challenge for diabetes care professionals who have to manage people observing the Ramadan fast. It provides practical guidance regarding various aspects of diabetes management during the holy month.
Apart from the knowledge of clinical pharmacology and clinical diabetology, proper management of diabetes in Ramadan requires detailed understanding of pathophysiological and psychosocial aspects as well. These are covered in chapters on the endocrinology of fasting, counseling and risk stratification.
The therapeutic challenge of diabetes care is addressed in various ways. The nonpharmacological and drug management of diabetes are also discussed in detail. The various domains of nondrug therapy: nutrition, physical activity and stress management, are given their deserved place in the schemata of the book. Similarity, the sempiternal topics of insulin and oral therapy during Ramadan get full attention. Along with this, the monitoring of glycemic control, an essential part of diabetes care, is discussed. Special issues which arise during Ramadan are also included. Fasting in women and in adolescents is given separate coverage in the book.
Successful completion of Ramadan is a great achievement for believers and provides spiritual merit. Helping others in their achievement is equally meritorious. Through its chapters, this book tries to facilitate the observance of healthy Ramadan fast, in millions of Islamic adherents with diabetes.
He (PBUH) said: “No blessing other than faith is better than well-being”.
REFERENCES
- WHO definition of Health. [online] Available from http://www.who.int/about/definition/en/print.html. [Accessed on 18 June 2013].
- Bashir MI, Pathan M, Raza SA, et al. Role of oral hypoglycemic agents in the management of type 2 diabetes mellitus during Ramadan. Indian J Endocr Metab. 2012; 16:503–7.
- Engel GL. The need for a new medical model: a challenge for biomedicine. Science. 1977;196(4286):129–36.
- Adler RH. Engel's biopsychosocial model is still relevant today. J Psychosom Res. 2009; 67 (6): 607–11.
- Committee on Quality of Health Care in America: Institute of Medicine: Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC: The National Academies Press; 2001.
- Niazi AK, Kalra S. Patient centred care in diabetology: an Islamic perspective from South Asia. J Diabetes Metab Disord. 2012;11:30.
- Pathan M, Sahay RK, Zargar AH, et al. South Asian Consensus Guideline: Use of insulin in diabetes during Ramadan. Indian J Endocr Metab. 2012; 16:499–502.
- Kalra S, Unnikrishnan AG, Skovlund SE. Patient empowerment in endocrinology. Indian J Endocr Metab. 2012; 16:1–3.
- Jaleel MA, Raza SA, Fathima FN, et al. Ramadan and diabetes: As-Saum (The fasting). Indian J Endocr Metab. 2011; 15:268–73.
- Pathan M, Sahay RK, Zargar AH, et al. South Asian Consensus Guideline: Use of GLP-1 analogue therapy in diabetes during Ramadan. Indian J Endocr Metab. 2012; 16:525–7.
- Bajwa SS, Kalra S. Logical empiricism in anesthesia: A step forward in modern day clinical practice. J Anaesthesiol Clin Pharmacol. 2013; 29:160–1.