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Paper presented to postgraduate students in the Master of Science (Primary Health Care) Institute of Medicine, Universiti Brunei on 11th September 2008 by Professor Omar Hasan Kasule MB ChB (MUK), MPH (Harvard), DrPH (Harvard) Professor of Epidemiology and Islamic Medicine. WEB: http://omarkasule.tripod.com
ABSTRACT
The leading theme of this paper is that self control regarding appetite for food (both total quantity and type) is the most important element in the prevention of diabetes and many of its complications. This paper discusses two issues relevant to diabetes mellitus: prevention of the disease or its aggravation by appetite control and care for the diabetic patient who desires to undertake puasa. Diabetes is closely related to nutrition. Overweight and obesity are risk factors of diabetes occurrence and diabetic complications. Diabetic patients on treatment need to have proper control of their dietary intake to avoid complications. Diabetic patients who wish to perform puasa need to have their diet controlled. In some cases they are exempted from puasa altogether.
1.0 CONCEPTS ABOUT HUMAN NUTRITION
1.1 Levels Of Human Nutrition
At the lowest level, humans eat to satisfy basic survival needs and necessities, dharuuraat. At the next level humans eat to satisfy wants, haajiyaat. At the next level humans eat food with refinements and embellishments, tahsiinaat. At the highest level feeding is associated with several complementaries, mukammilaat. Cooking rice is a pot of water and consuming it directly from the pot will satisfy dharuuraat. Cooking the rice with some sauce and flavoring will satisfy haajiyaat and will enable the person to eat more because the food is more palatable. Serving the rice on nice plates and with other foods and drinks is tahsiinaat. Eating the rice with friends on nice decorated tables with music in the background is considered mukammilaat. The level of nutrition depends basically on the level of socio-economic development. The higher the socio-economic level the higher the level of nutrition. However from the biological point of view, a higher level of nutrition does not translate into better health outcome. It seems that the basic foods are more healthy and there is now a movement to return to simple healthy foods.
1.2 Appetite For Food
Humans have an appetite for food that is a very strong instinct. The strong appetite is because food is needed for survival. The appetite and hence the search for food start even before the body is in physical need of nourishment. The feeling of hunger is a warning sign of nutritional depletion in the next few hours and does not signal actual starvation. The phenomena of hunger and thirst are sometimes psychological. A person will feel hungry at a time when he normally takes his meals or when food is smelled. People would starve to death if the feeling of hunger coincided with actual depletion of food reserves. Human appetite is under the control of the hunger center, the thirst center, and the limbic system. Anorectic drugs e.g. amphetamine suppress the appetite. Appetite stimulants increase the desire for food. The human appetite for food is so strong that prayer is delayed when food is presented[i]. It is conceivable that a hungry person will not concentrate sufficiently in salat.
1.3 Energy Input And Output
The human body can be visualized as a chemical factory with inputs of food and other essentials like oxygen and outputs such as energy and complex molecules. The body essentially converts chemical energy of the organic molecules in the food into various forms of energy needed by the body (mechanical, electrical, chemical etc). Like all machines the process of conversion produces heat as a side effect. In human-made machines heat is considered as lost energy which reduces the efficiency of the machine’s energy conversion. However in the case of the human body, the heat produced is directly useful because it is needed to maintain optimum body temperature. Humans are homiotherms who must maintain body temperature within a very narrow band of variation because metabolic reactions can only be efficient at that temperature. This indicated the superiority of Allah’s creation which is most efficient and is not comparable to human creation.
The amount of energy needed by an individual is affected by: surface area, age, sex, and level of physical activity. Big and active people need more energy. Children and the elderly need less energy
The Basal Metabolic Rate (a measure of energy expenditure) per weight and surface area at rest is lower in women because of more adipose tissue and because men are more active. BMR is increased after a meal (the specific dynamic action of food) and after exercise. BMR is not affected by mental activity.
Most energy expenditure is for contracting and moving muscles. It is a tragedy of modern civilization that humans still take three meals a day like their ancestors when they live sedentary lifestyles with limited physical activity.
Energy intake in excess of energy expenditure translates directly into obesity and disease. The Law of conservation of energy holds true for the human body. Thus any violation of the Law of Allah, sunnat al llaah, about conservation of energy results into misfortune.
1.4 Nutritional Habits And Human Corruption
The type of food and nutritional habits reflect underlying visions, beliefs, and cultural experience of individuals and societies. On the other hand one's nutritional habits may affect the way of behavior and approach to life. For example many daily activities revolve around meal routines and there is a big difference observed in Ramadhan when those routines are interrupted. The alimentary system can be looked at as the final pathway for human corruption. Since food security is the most important concern of life, humans strive by all means fair and foul to ensure they will survive. Thus food security is the underlying but often unstated purpose behind crime, corruption, treachery, amassing of wealth, aggression, and many other transgressions. The worst manifestations of this is genocide and feticide when humans do not want more mouths to share what they think is a limited food supply but in the sight of Allah every living thing has its allocated rizq. The Qur'an condemned those who kill their children for fear of poverty and assured that Allah provides for both the parents and the children.
1.5 Significance Of Fasting Periods
PHYSIOLOGICAL FASTING
A human can survive for periods without food. Usually nights are periods of fasting. In a very revealing hadith the Prophet taught that supper should not be abandoned even if it is one date[ii]. This is in view of the prolonged period of physiological fasting during sleep. Even during the day humans do not eat continuously. There are periods of fasting during the day between meals or during Ramadhan.
Humans can ingest 100 times more food than their immediate caloric needs. This food, in the form of glycogen and fats, is stored for later use. The storage capacity is however limited. Glucose storage is only 100g in the liver and 250 g. in muscles. Lipid deposits store fats. Food storage enables humans to fast from meal to meal. However fasting cannot be prolonged beyond a certain period because of the critical need of the brain for glucose. At rest the brain consumes 66% of the circulating glucose and requires 100-150g of glucose per day. Unlike other tissues it can not utilize fatty acids. Lipid deposits and muscle protein can be mobilized when needed but for a limited duration. In starvation muscles are broken down to provide proteins.
RELIGIOUS FASTING
Fasting of Ramadhan is one the major acts of obligatory physical ibadat. Besides the benefit of fulfilling an act of ibadat, fasting cleanses the body, al siyam zakat al jism[iii]. It is also a protection, al siyaam junnat[iv]. Voluntary hunger in Ramadhan gives the rich practical experience of hunger that makes them understand and appreciate the suffering of the poor
2.0 CONTROL OF APPETITE
2.1 States Of Satiety, Maraatib Al Ghadha
Satiety can be described in three states: the necessary, dharurat; the needed, haajat; and the excess, fadhl. Dharurat is the minimum nutritional intake necessary to maintain health in the best status. It represents the balance between excessive and too little intake. Haajat is intake that is more than dharurat but which prevents the feeling of hunger. It is however recommended not to eat to full satisfaction, shaba’u. Fadhl is the excess intake beyond the need.
2.1 Control Of Appetite By Iman
There is a difference in attitude to feeding behavior between the believer and non-believer[v] [vi]. he etiquette of eating is determined by the underlying vision. The believer eats to get energy for ibadat. The non-believer may eat for enjoyment or to get energy for evil. The Prophet described Muslims as a community who ideally eat only when hungry and who do not fill their bellies when they eat, nahnu qawmu la na akul hatta najuu’u wa idha akalna fala shabi’ina.T. There is blessing in the food of the believer; he gets satisfied easily. The non-believer has to eat more food to get satisfaction. The Prophet Muhammad (PBUH) in a very revealing hadith mentioned that a believer eats in one stomach whereas a non-believer eats in 7 stomachs. This means that a believer is satisfied with less food than a non-believer.
2.2 Control Of Appetite By Fasting
Both obligatory and nafilat fasting help in controlling excess intake. The fasting person takes and absorbs less food in a day that a non-fasting one. Fasting is also training in appetite control during the ensuing non-fasting period.
3.0 PROBLEMS OF SATIETY
3.1 The principle of equilibrium, mizan
Satiety is the desire to stop eating further because of feeling satisfaction. It is controlled by the hypothalamus. Eating causes a rise in body temperature that signals to the hypothalamus to activate the satiety mechanisms. The distension of the stomach during a meal also sends signals that activate satiety. High blood sugar and high lipid levels may also cause satiety. Emotional and psychological factors also control satiety. In normal circumstances these negative feedback mechanisms can keep food ingestion within physiologically acceptable levels. However human will is able to overrule normal physiological control mechanisms. The body may crave for more food but the will can overrule it. In the same way the will can cause stopping feeding even before satiety is reached. Over eating or under-eating due to the action of the human will can be the basis for malnutrition and human disease.
3.2 Over-Nutrition
The diseases of over-nutrition are: obesity, diabetes mellitus, ischemic heart disease, and atherosclerosis. These diseases are more common in the rich countries with a higher prevalence of over-nutrition. The prophet taught the rule of the thirds (musnad Ahmad) as a guide for food intake: one third for solid food, one third for water, and one third for air. He also taught that Muslims are a community who do not eat until they are hungry and when they eat they do not fill their belly. Ibn al Qayim defined three levels of food: necessary, hajat, sufficient, kifayat, and excess, fadhlat. The necessary amount of food is that necessary for maintenance of life and health. The sufficient is more than the necessary and satisfies the psychological desire for food. The excess is what is beyond the body's needs and is definitely harmful to health. Early man in agricultural societies could use up all the food ingested because of the hard physical work of looking for food and assuring the basic necessities of life. Sedentary man in the modern industrial society still eats the same number of meals as early man without the same amount of physical work with the result that obesity develops.
Fatness, sumn, was mentioned in the Qur'an in relation to animals being fed well and getting fat[vii]. We did not identify direct mention of human obesity. In a hadith reported by Aisha, the prophet described obesity as one of the signs of social degradation. The Qur'an described some food as fattening whereas other food is not; for example food of hell is non-fattening. Obesity is deviation from homeostasis. Obesity could be caloric or genetic; there is interaction between the two forms. Caloric obesity develops when energy intake exceeds energy expenditure. In that situation the equilibrium between lipolysis and lipid storage is shifted in favour of storage. There is accumulation of fat. This affects androgen and estrogen metabolism. Atheroma and physical disabilities also develop.
3.3 Obesity
Obesity is excessive accumulation of fat in the body when more energy is ingested that is expended. The excess energy is stored as fat. Fat in the sub-cutaneous tissue is easy to see and measure. However fat inside the body is calculated from the specific gravity of the body obtained by comparing weight in water with weight in the air. Fat tends to lower body specific gravity.
Obesity is a social and medical disease that was condemned by the prophet. He considered it a sign of social degeneration. Most cases of obesity are due to excess food intake although emotional, genetic, and endocrine factors play a role. Obesity may also be familial with no genetic basis when children grow in a family with excessive nutritional intake and grow into overweight or obese adults. Regular food intake without any physical activity may also lead to obesity. Overeating may be stimulated by certain drugs. In some cultures obesity especially of women is considered a sign of beauty and special medications are taken to achieve it. Factors that encourage over eating include: abundance of food with a lot of leisure time leading to social eating as entertainment and stress that finds relief in food.
Obese persons have a shorter life-expectancy. Obesity is associated with hypertension, atherosclerosis, and diabetes. Obesity is an increased burden for the heart and also the skeleton and joints. Behavioral problems may be due to feeling bad about one self and may progress to neuroses and psychoses. Besides its association with disease, obesity in its extreme forms interferes with performance of physical acts of ibadat such as saum, salat, and hajj. Obesity is treated by reducing food intake under medical supervision
4.0 GENERAL HEALTH GUDELINES DURING PUASA
4.1 The prophet (PBUH) taught measures to ensure that puasa does not cause physiologic damage. Puasa continuously from day to day, wisaal, was forbidden[viii]. Early iftaar was recommended[ix]. Delaying suhuur was recommended[x].
4.2 There are medical guidelines on diet in puasa. The aim should be maintaining normal body weight or actually reducing it if overweight. Over-eating at iftaar and suhuur should be avoided. It will cause weight gain and indigestion. The diet should contain sufficient fiber to prevent constipation. Fiber and slowly digested foods with a long stomach transit times are preferred because they delay the feeling of hunger. Enough water should be taken at night both for preventing dehydration and preventing constipation. Adequate fluid and salt intake prevents lethargy in the afternoon caused by low blood pressure.
4.3 Inadequate sleep is a cause of headaches. Intake of adequate calcium, magnesium, and potassium will prevent muscle cramps. Hot places should be avoided because they aggravate the dehydration. Cooling the body such as tepid sponging, tabarrud, is allowed[xi] during puasa.
5.0 CARE FOR DIABETICS DURING PUASA
5.1 Beneficial health benefits of puasa
The merits of puasa, fadhl al siyaam, are many and are varied but all of them have medical or health implications.
Puasa breaks the normal routines of life that revolve around meals. It creates a different psychological milieu that liberates the mind from the routines of life and gives it an opportunity to reflect on the bigger issues of the creator, the good and the bad. Puasa in this way leads to psychological satisfaction because of the liberation from the dominating and sometimes constraining daily routines of life.
The medical merits are appetite and weight control. Puasa teaches a person to control the food appetite during the day for 30 days every year. Avoiding food or drink for a hungry and thirsty person requires self discipline and self control that are empowering. This empowerment can be transferred to other life activities. The training is repeated every year.
5.2 Diabetes mellitus and puasa
Diabetes has special consideration in puasa because of its direct relationship with food intake. Insulin-dependent diabetics have to reduce their insulin dose because of reduced food intake during the day. In some cases this is not possible and they have to be exempted from puasa altogether especially if their diabetic control is brittle. Insulin-dependent diabetics should be monitored very carefully because hypoglycemia may arise due to insulin injections with inadequate dietary intake. Non-insulin diabetics can undertake puasa under medical supervision. This will generally require changing times of medication, close monitoring of blood sugar levels, and being alert to any hyperglycemic or hypoglycemic crises. Pregnant diabetics are exempted from fasting because diabetic control is more difficult in pregnant women making fasting doubly hazardous for both the mother and the fetus.
5.3 Effect of puasa on diabetics
Studies on the effect of puasa on diabetic control have given many contradictory results. This is due to lack of careful control for confounding factors and the general change in dietary habits that occurs in Ramadhan compared to other months of the year. We will here quote only 2 of such studies.
Azwany et al [xii] studied the impact of Ramadan fasting on glycemic control in type 2 diabetes patients. Forty-three Muslim type 2 diabetic patients or oral medication, with no renal or liver disease participated in the study. A total of 52 patients had been recruited giving a drop-out rate of 17.3%. Fasting blood glucose (FBG) and serum fructosamine levels were determined at four consecutive visits (at four weeks and one week before Ramadan, in the fourth week of Ramadan and four weeks after Ramadan). They found no significantly change in mean FBG over time (Figure 1, p=0.12). There was however an increase in fructosomine from the first to the fourth weeks (figure 2, p=0.001). The study showed poor diabetic control because the subjects were more hyperglycaemic in Ramadhan. They concluded that the poor control reflected lack of knowledge about adjusting diet and medication during Ramadhan.
Yousef et al[xiii] undertook a study to study the effects of Ramadhan on various physiological parameters in normal and diabetic patients (NIDDM). The study group consisted of 53 diabetic patients (31 male and 22 female) and 56 (21 male 35 female) healthy volunteers as controls. The subjects were evaluated 1-2 weeks before commencement of fasting (visit 1), at the 4th week of Ramadan fasting (visit 2) and one month after the end of the Ramadan fast (visit 3). Results are shown in Tables 1 and 2. They found statistically significant weight reduction (P<.001) at the end of Ramadan fast in both groups which was not maintained one month after Ramadhan. Fasting blood sugar and HBA1C showed significant reduction (P<.001) among diabetics but not in control group. However serum cholesterol, triglyceride, and uric acid increased among healthy volunteers (control group) one month after Ramadan; no such changes were seen among diabetic group.
Notes
[i] (Muslim H1134, Muslim H1137, MB403)
[ii] Tirmidhi K23 B46; Ibn Majah K29 B54
[iii] Ibn Majah K7 B44)
[iv] Ahmad 1:195
[v] Bukhari K70 B12
[vi] Bukhari K70 B12
[vii] (p599 12:43, 12:46, 51:26)
[viii] Bukhari K30 B20
[ix] Bukhari K30 B45
[x] Ahmad 5:147
[xi] Bukhari K30 B22
[xii] N. Azwany , Aziz A Ismail, W.B.W. Mohammad\, A.K.Al-Mahmood.: Effect Of Ramadan Fasting On Glycemic Status Of Type 2 Diabetic Patients In Northern Malaysia. International Medical Journal Vol 2 No 2 December 2003
[xiii] R M Yousuf, MD, A R M Fauzi, MRCP, S H How, M. Med, A Shah, MSc. Metabolic Changes During Ramadan Fasting In Normal People And Diabetic Patients. International Medical Journal Vol 2 No 2 December 2003