Managing Diabetes in Practicing Muslims during Ramadan

Population trends and global health initiatives have tremendous implications for the future of nursing and healthcare practices. An expanding Muslim population and the increasing rate of diabetes in this population make the management of diabetes in the Muslim patient a prevailing concern for healthcare providers.

Muslims are currently estimated to comprise 18-25% of the world’s population with trends predicting continued expansive growth2. Diabetes is the most common endocrine disorder that occurs from either lack of sufficient insulin production by the body or lack of adequate body response to the insulin produced or a relative combination of both clinical situations3. Type 2 diabetes has been identified as an emerging health crisis for Muslims affecting nearly 11% of their population4. The prevalence of diabetes is forecast to increase by 64% through 2025, making management of diabetes in this Muslim patient an epidemiological concern for current and future nursing practice5. These staggering figures cannot be resolved without the efforts of increased awareness, knowledge, and primary care.

Effects of Fasting

The practice of Islam requires healthy Muslims to adhere to a strict diet throughout the year which becomes increasingly more strict during the month of Ramadan (the ninth month of the Islamic calendar) which includes fasting practices6. The fasting occurs throughout the day with most Muslims eating one considerably large or two larger meals during late evening or nighttime hours. The Muslim diet tends to include more high-caloric and high-sugar foods during this time to account for their normal metabolic requirements and to overcome the fast. This practice can have major health-related consequences for those diagnosed with diabetes or are pre-diabetic6. The fasting practices of Muslims during Ramadan are not endorsed by medical professionals and the resultant hypoglycemia accounts for roughly 2-4% of mortality among type 1 diabetics1.

The inclination of Muslims to consume larger meals of high-caloric foods with high sugar content subsequently results in many Muslim diabetics being at risk for various metabolic conditions. This should be addressed as part of a comprehensive education program and brought to their attention. It is important for the culturally sensitive nurse to value the patient’s cultural practices and respect their wishes to participate in the fasting practice.

The diet is considered the most important factor in the management of diabetes12. Because of the restrictive nature of their consumption, a nutrition consultation is appropriate. Thus, meals should contain healthier food choices consistent with Islamic teachings, occur throughout the day (especially during physical activities), and medication regimens should be adjusted accordingly. The Muslim diet restrictions (haram) not only include pork products, but also include gelatin, alcohol, blood, humans’ substances, “unlawful” animals, birds, and non “halal” food (those which are allowed to be consumed)13. Lawful animals are those that have been slaughtered in a manner consistent with their faith – acknowledging Allah prior to the slaughter. Muslims thank Allah both before and after eating and use only their right hands to consume food 13. Muslims also avoid eating anywhere non-halal foods are served or prepared or anywhere there may be smoking.

Understanding of Faith Practices

The implications are quite clear: diabetes education and understanding of the practices of Muslims can be valuable components in implementing culturally competent nursing care. An appreciation for cultural practices and enhanced cultural competence are essential to improving patient care and reducing disparities that exist among minority and ethnic populations7. In order to narrow the gap nurses need to provide more culturally sensitive, ethical, and collaborative care, valuing diversity8. The large population of Muslims in the world reflects broader global health implications though they remain a minority in the US.

SEE ALSO: Earn CE: Cultural Competency

Management of the diabetic Muslim patient during Ramadan begins with preparation for the advent of the holy month, understanding their faith, and corresponding education. The Islamic faith makes exceptions to fasting requirements for those who are considered ill, though many diabetic Muslims will not consider themselves ill and remain steadfast in observing their faith practices1. Accordingly, illness is defined by the person experiencing the illness9. Illness, pregnancy, old age, and those who will be traveling may be exempt from fasting7.

Culture, however, is influential in the way we define health and illness. In this circumstance, the patient is not disregarding medical advice but demonstrating the importance of their faith as a priority. Thus, valuable information can be obtained in speaking to patients about their faith practices.

The preparation for Ramadan should include a scheduled office visit with a family practitioner to assess their current health status and help them construct a plan of care for the following month. Because Muslim fasting practice is ongoing from prior to sunrise through after sunset, it is important that they understand their body’s metabolic and medical needs and coordinate healthier meal options and medication regimens in preparation.

Patient Knowledge of Disease Processes

Ensuring the patient comprehends their disease process, is provided comprehensive information regarding nutrition, and fully understands their medications are crucial. Methods of reinforcing understanding may include: repeat explanation of the disease process and plan, literature to peruse, written journals, follow-up phone calls, and collaborative efforts with the patients family. Collaboration with interdisciplinary professionals may be warranted as collaborative care has been shown to improve patient outcomes and empower the patient10. These steps are important in ensuring the patient, family, and providers are aware of any current or impending issues.

The Islamic faith forbids consumption of pork products, which precludes Muslim diabetics from receiving insulin derived from porcine origin. Human insulin preparations are considered acceptable to Muslims. Because of the consumption of rich caloric (and high sugar content) food, a diabetic patient may experience relative hyperglycemia. After long periods of fasting, the patient may conversely experience hypoglycemia.

It is important for Muslim diabetics to understand that fasting may also result in hyperglycemia during periods of stress. In fact, the stress on the body from fasting may increase circulating levels of growth hormones, glucose, cortisol, and catecholamines that increase circulating glucose levels and suppress insulin release11. For the Muslim living with diabetes, not having an actionable plan of care may initiate a sequence of compounding metabolic complications.

Diabetic Warning Signs

Understanding the clinical symptoms associated with altered states of blood glucose may assist patients or family members in identifying a clinical situation so treatment can be initiated immediately. Though many diabetics are familiar with these symptoms and their body’s responses, it is an opportunity to inform family members and reinforce content. Signs and symptoms of hypoglycemia may include confusion, hunger, anxiety sweating, trembling, visual disturbances, and palpitations14. Signs of hyperglycemia include polyuria, polydipsia, and polyphagia, headache, and fatigue. Because it is not always easy to predict when these symptoms may become present, it is important that the patient always have their insulin or source of glucose accessible.

If a diabetic is feeling that their glucose levels are aberrant, they should immediately test their blood glucose levels. If glucose levels are low (<70 mg/dl) they should be instructed to consume food or beverages that will raise their glucose levels to normal range and eliminate symptoms. If their glucose levels are high (>200 mg/dl) they may require insulin. If a patient cannot manage their glucose levels during Ramadan with these simple recommendations, they should inform their primary care provider and reconsider their fast. Instruct patients to seek immediate medical attention if any signs of clinical deterioration beyond normal variant occurs – even if the patient is feeling ok15.

When satisfactory education has been completed with the patient and/or family, it is important to follow-up with the patients to ensure their adherence to the plan. Evaluating the plans successes and failures for patient-specific modification exemplifies commitment to the patients experience and ensures quality care is consistently being observed. Incorporating planning and process to exact more patient-specific outcomes is a hallmark of the collaborative care process16.

 

Richard R. Tennesen works in the Reading Health System, Reading, Penn.


References

1. Al-Arouj, M., Bouguerra, R., Buse, J., Hafez, S., Hassanein, M., Ibrahim, M. A., Ismail-Beigi, F., El-Kebbi, I., Khatib, O., Kishawi, S., Al-Madani, A., Mishal, A. A., Al-Maskai, M., Nahki, A. B., & Al-Rubean, K. (2005). Recommendations for management of diabetes during Ramadan. Diabetes Care28(9), 2305-2311.

2. Olgun, N. (2006). The effect of Ramadan fasting on well-being and attitudes towards diabetes in patients with diabetes. European Diabetes Nursing3(2), 79-84.

3. Hines, R. L. & Marschall, K. E. (2009). Handbook for Stoelting’s anesthesia and co-existing disease, (3rd ed.). Philadelphia, PA: Saunders Elsevier.

4. Peterson, S., Nayda, R. J., & Hill, P. (2012). Muslim person’s experiences of diabetes during Ramadan: Information for health professionals. Contemporary Nurse41(1), 41-47.

5. Rowley, W. R., & Bezold, C. (2012). Creating public awareness: State 2025 diabetes forecasts. Population Health Management15(4), 194-200).

6. Pinar, R. (2002). Management of people with diabetes during Ramadan. British Journal of Nursing11(20), 1300-1303).

7. Andrews, M., & Boyle, J. (2012). Transcultural concepts in nursing care (6th ed.). Philadelphia, PA: Lippincott, Williams, & Wilkins.

8.Fowler, M. D. M. (2008). Guide to the code of ethics for nurses: Interpretation and application. Atlanta: American Nurses Association.

9. Spector, R. (2013). Cultural diversity in health and illness (8th ed.). Upper Saddle River, NJ: Pearson Prentice Hall.

10. Ellingson, L. L. (2002). Communication, Collaboration, and Teamwork among healthcare Professionals http://cscc.scu.edu/trends/v21/v21_3.pdf

11. Barash, P. G., Cullen, B. F., Stoelting, R. K. (2001). Clinical anesthesia, (4th ed.). Philadelphia, PA: Lippincott Williams & Wilkins.

12. Stoelting, R. K. & Dierolf, S. F. (2002). Anesthesia and co-existing disease (4th ed.). Philadelphia, PA: Churchill Livingstone.

13. Faithandfood.com (n.d.). Faithandfood fact files – Muslim. Retrieved from http://www.faithandfood.com/Islam.php

14. Mayo Clinic staff (2012). Hypoglycemia. Retrieved from http://www.mayoclinic.com/health/hypoglycemia/DS00198/DSECTION=symptoms

15. Holmes, P. (2013). Diagnosing diabetes: getting it right from the start. Practice Nursing24(4), 187-190.

16. Freshman, B., Rubino, L., & Chassiakos, Y. R. (2010). Collaboration across the disciplines in healthcare. Sudbury, MA: Jones and Bartlett Publishers.