Recommendations for management of diabetes and its complications during Hajj (Muslim pilgrimage).

Hajj is one of the five pillars of Islam and is a must-do for all adult Muslims once in their life provided they are able to do it. Considering the 8.8% global prevalence of diabetes, coupled with the number of Muslims performing Hajj (~2.5 million adult Muslims), it could be estimated that Muslims with diabetes performing Hajj may exceed 220 000 per year. According to Islamic rules, Hajj should not cause severe difficulties for Muslims. The Holy Qur'an specifically exempts from this duty Muslims who are unable physically or financially if it might lead to harmful consequences for the individual. This should be applicable to subjects with diabetes considering its severe and chronic complications. During the Hajj, diet, amount of fluid intake and physical activity may be altered significantly. This exemption from the duty is usually not considered a simple permission; Muhammad the Prophet of Islam mentioned, 'God likes his permission to be fulfilled, as he likes his will to be executed'. However, most Muslims with diabetes prefer to do the Hajj duty, and this may cause major medical challenges for Muslims with diabetes and their healthcare providers. So it is very important that healthcare providers are aware of the possible risks that could happen during the Hajj. People with diabetes may face many health hazards during the Hajj, including but not limited to the 'killer triad': hypoglycemia, foot injury and infections. Many precautions are necessary in the prevention and treatment of possible serious complications. Risk stratification, medication adjustments, proper clinical assessment, and education before doing the Hajj are crucial.

Recommendations for management of diabetes during Ramadan: update 2015.

Since the first ADA working group report on the recommendations for management of diabetes during Ramadan in 2005 and our update in 2010, we received many inquiries asking for regular updates on information regarding education, nutritional habits and new oral and injectable agents that may be useful for the management of patients with diabetes during Ramadan. Patients can be stratified into their risk of hypoglycemia and/or complications prior to the start of the fasting period of Ramadan. Those at high risk of hypoglycemia and with multiple diabetic complications should be advised against prolonged fasting. Even in the lower hypoglycemia risk group, adverse effects may still occur. In order to minimize adverse side effects during fasting in patients with diabetes and improve or maintain glucose control, education and discussion of glucose monitoring and treatment regimens should occur several weeks prior to Ramadan. Agents such as metformin, thiazolidinediones and dipeptidyl peptidase-4 inhibitors appear to be safe and do not need dose adjustment. Most sulfonylureas may not be used safely during Ramadan except with extreme caution; besides, older agents, such as chlorpropamide or glyburide, should not be used. Reduction of the dosage of sulfonylurea is needed depending on the degree of control prior to fasting. Misconceptions and local habits should be addressed and dealt with in any educational intervention and therapeutic planning with patients with diabetes. In this regard, efforts are still needed for controlled prospective studies in the field of efficacy and safety of the different interventions during the Ramadan Fast.

Impact of an individualized type 2 diabetes education program on clinical outcomes during Ramadan.

OBJECTIVE: To determine if individualized education before Ramadan results in a safer fast for people with type 2 diabetes. METHODS: Patients with type 2 diabetes who received care from participating clinics in Egypt, Iran, Jordan and Saudi Arabia and intended to fast during Ramadan 2014 were prospectively studied. Twelve clinics participated. Individualized education addressed meal planning, physical activity, blood glucose monitoring and acute metabolic complications and when deemed necessary, provided an individualized diabetes treatment plan. RESULTS: 774 people met study criteria, 515 received individualized education and 259 received usual care. Those who received individualized education were more likely to modify their diabetes treatment plan during Ramadan (97% vs 88%, p<0.0001), to perform self-monitoring of blood glucose at least twice daily during Ramadan (70% vs 51%, p<0.0001), and to have improved knowledge about hypoglycemic signs and symptoms (p=0.0007). Those who received individualized education also reduced their body mass index (-1.1±2.4 kg/m(2) vs -0.2±1.7 kg/m(2), p<0.0001) and glycated haemoglobin (-0.7±1.1% vs -0.1±1.3%, p<0.0001) during Ramadan compared those who received usual care. There were more mild (77% vs 67%, p=0.0031) and moderate (38% vs 19%, p<0.0001) hypoglycemic events reported by participants who received individualized education than those who received usual care, but fewer reported severe hypoglycemic events during Ramadan (23% vs 34%, p=0.0017). CONCLUSIONS: This individualized education and diabetes treatment program helped patients with type 2 diabetes lose weight, improve glycemic control and achieve a safer fast during Ramadan.