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DIABETES AND PUASA

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Background material by Professor Omar Hasan Kasule Sr. for Year 3 Semester 2 Med PPSD session on Monday 12th January 2009

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.

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.

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 [i] 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[ii] 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.


FIGURE 1: MEAN FBG (MMOL/L) IN 43 SUBJECTS BY WEEK IN RELATION TO RAMADAN


FIGURE 2: MEAN SERUM FRUCTOSAMINE LEVEL (mMOL/L) IN 43 SUBJECTS BY WEEK IN RELATION TO RAMADAN.


*Significant difference from 4th week of Ramadan p<0.001




TABLE 1: LABORATORY VALUES* TESTED AMONG DIABETIC PATIENTS AND CONTROLS BEFORE FASTING (VISIT 1) AND DURING RAMADAN (VISIT 2). Data is show  

Diabetic patients (n=53)
Controls (n=50)
                  
Visit 1
Visit 2
P value
Visit 1
Visit 2
P value
Weight(kg)

70.7±12.6

69.8±12.6
.012
60.6±13.7
58.6±12.4
.001
Fasting blood sugar (mmol/L)
10.6±4.1
8.5± 3.4
.001
5.6± 0.70
5.4±0 .71
NS
Cholesterol (mmol/L)
5.7±1.08
5.9 ±0.9
NS
5.4 ±  0.9
5.6 ± 0.9
NS
Triglyceride(mmol/L)
1.8± .93
1.7 ±0.9
NS
0.8±0 .51
0.8 ± 0.6
NS
Urea(mmol/L)
4.2± 1.5
4.5±2.3
NS
3.6± 1.07
3.8± 2.3
NS
Creatinine(mmol/L)
82.±26
86±28
NS
76.2 ±2.4
76.04± 19
NS
Uric acid (micromol/L)
385±134
376±97
NS
281.3± 85
290± 77
NS
*all values are expressed as mean ± standard deviation
NS: not statistically significant



TABLE 2: LABORATORY VALUES* TESTED AMONG DIABETIC PATIENTS/ CONTROLS BEFORE FASTING (VISIT1) AND ONE MONTH AFTER FASTING (VISIT3):   

diabetic patients n=50
controls  n=48



Visit 1

Visit 3

P value
Visit 1

Visit 3

P value
Weight (Kg)
70.8±12.6
70.7± 12.5
NS
60.5±13.8
59.1±13
NS
Fasting blood sugar (mmol/L)
10.8±4.1
9.06±3.8
.002
5.5±0.6
4.9±0.7
NS
HBA1C
7.35±2.03
6.7±1.6
.001
4.84±0.6
4.86±0.5
NS
Cholesterol(mmol/L)
5.7±1. 09
5.7± 1.16
NS
5.5± 1
5.8 ±1.16
.001
Triglyceride(mmol/L)
1.7±0.4
1.8±1.3
NS
0.78±0 .5
1. ±0.6
.001
Urea(mmol/L)
4.1±1.4
5±2.5
NS
3.5±1
4.3±1.3
NS
Creatinine(mmol/L)
79.4±23
81±26.3
NS
75.5±17
90±22
NS
Uric acid (micro mol/L)
381±136
365±109
Ns
278±84
320±95
0.01
 
*all values are expressed as mean 7±  standard deviation
 NS: not statistically significant.

[i] 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
[ii] 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