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Patients who fast during Ramadan are at a risk of complications if they do not do it right. Joan Chew reports
 More than two in five Muslim diabetic patients here have had bouts of low blood sugar during Ramadan, the month-long period of fasting, a recent survey has shown. These hypoglycaemic episodes are clinically defined as when the blood glucose level falls below 4 millimoles per litre (mmol/L). When this happens, a person experiences symptoms such as sweating, dizziness, confusion and a raised heartbeat and should immediately break fast, doctors say. Yet 5.6 per cent of those with these symptoms continue to fast, putting themselves at risk of loss of consciousness, convulsions or seizures. Over two months last year, the survey asked 92 patients at the Singapore General Hospital (SGH), the majority of whom had type 2 diabetes, how they had managed their disease before and during Ramadan the previous year. In type 2 diabetes, the body’s cells cannot use insulin properly to keep blood sugar levels normal, while type 1 diabetes is a condition where the body produces little or no insulin. Insulin is a hormone that maintains blood sugar levels.
The survey results were presented during the 72nd American Diabetes Association Scientific Meeting at the Pennsylvania Convention Center in Philadelphia, the United States, in June this year. They showed that many Muslim patients with diabetes here are not aware of their risk of complications during fasting. One in five answered fewer than half the questions correctly in a questionnaire to track what they knew about diabetes mellitus, such as the symptoms of low and high blood sugar levels and the methods of safe fasting during Ramadan. The mean score was just 58.6, out of a possible score of 100. About two-thirds (66.7 per cent) of the respondents said they had discussed fasting with their primary physicians – an advisable move because treatment regimens and medication dosages may need to be altered.
The study confirmed what lead author Abel Soh, a consultant at the department of endocrinology at SGH, had suspected: It was not routine for Muslim diabetic patients to prepare for Ramadan by visiting their doctors. More than a third (35 per cent) said they monitored their blood sugar during Ramadan, though it was not asked how often they did so. This figure worries Dr Soh, who said type 1 diabetics should ideally check their blood sugar levels daily and type 2 diabetics who need insulin injections should do so two to three times a week. Dr Sueziani Zainudin, a registrar at the department of endocrinology at SGH and one of the authors of the study, said misconceptions could be a reason Muslim patients choose not to monitor their condition. She said some mistakenly believe that pricking their finger to check blood sugar constitutes breaking fast, stemming from the belief that inserting a foreign object or substance into the body can invalidate one’s fast. For instance, if water enters a person’s nose while swimming, it constitutes the breaking of fast. But Dr Sueziani said since the finger prick is not done through a natural orifice, it does not invalidate one’s fast.
The knowledge gap among patients here has prompted at least two public hospitals to organise talks before Ramadan, which began on July 21. Tan Tock Seng Hospital (TTSH) attracted about 30 people to its free public forum held on July 7, while SGH had 23 diabetic Muslim patients attend workshops held last year and on July 14 this year. At the sessions, patients learnt to recognise the symptoms of low and high blood sugar – the major risks associated with fasting. A large study of more than 12,000 diabetics from 13 Islamic countries, published in the journal Diabetes Care in 2004, showed a high rate of complications in diabetics fasting during Ramadan. The risk of severe low blood sugar, which requires hospitalisation, grew by 7.5 times in patients with type 2 diabetes and almost five times in patients with type 1 diabetes. The risk of severe high blood sugar, requiring hospitalisation, rose by five times in type 2 diabetics and by about three times in type 1 diabetics.
Dr Abdul Shakoor S. K., a consultant at the department of endocrinology at TTSH, said the long gaps between food intake along with certain diabetes drugs put patients at risk of low blood sugar, or hypoglycaemia, during fasting. At the same time, the tendency to overeat when breaking fast may lead to a spike in sugar in the blood. Hyperglycaemia occurs when blood sugar goes beyond 16mmol/L. Dr Shakoor said patients unwittingly increase their risk of high blood sugar when they cut down or choose not to take medication while fasting. Symptoms include headache, fatigue, increased thrist, frequent urination and weight loss.
Another risk during fasting is thrombosis, the formation of a clot inside a blood vessel. Dr Shakoor said: “Thrombosis can happen when there is dehydration, which can be worse during Ramadan fasting as Muslims do not drink any fluids in the day time. This risk may be higher in those with higher blood glucose levels.” Diabetes is a growing scourge here, with 11.3 per cent of people aged 18 to 69 suffering from the chronic metabolic disease in 2010, up from 8.2 per cent in 2004. Among the races, Malays had the most dramatic increase in the proportion of diabetics, with 16.6 per cent suffering from diabetes in 2010, up from 11 per cent in 2004.
Madam Mehawa Osman, a 65-year-old housewife with type 2 diabetes, fainted from hypogylcaemia years ago, and was in hospital for three days. To prevent the unpleasant experience from recurring, she went to her doctor at Bedok Polyclinic a week before Ramadan this year and was told to adjust her twice-daily insulin jabs to match her food intake. She has lowered the dose of insulin in the morning to avoid low glucose levels while she fasts, but has increased the dose in the evening when she breaks fast for the day. Another patient with type 2 diabetes, Madam Pungut Wahid, a 64-year-old adjunct teacher who found the SGH workshop useful, now checks her blood glucose levels four times a day, before and after breakfast and dinner.
Ms Joyce Tan, a dietitian at the nutrition and dietetics department at TTSH, said patients should keep their blood sugar level stable with appropriate food choices. She advised Muslim diabetics to consume complex carbohydrates, such as brown rice, wholemeal bread and wholemeal chapatti (flatbread), before they start their fast, as these types of food are digested slowly, causing a slower increase in blood sugar level. They can also include more fibre-rich food, such as fruit and vegetables, to promote satiety. When they break fast, they should drink plenty of water and decaffeinated beverages to prevent dehydration. They should avoid sugary food and beverages, which will raise blood sugar, she said. Patients and their caregivers can also pick up safe fasting tips from pamphlets produced by drug company Merck Sharp Dohme and the Diabetic Society of Singapore, which are available at most general practitioners’ and endocrinologists’ clinics.
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