Working in the Kivunge diabetes clinic during Ramadan highlighted some of the health consequences that this important time can have. Islam is the prominent religion in Zanzibar and the vast majority of our patients fast for Ramadan.
This can be a particular challenge when managing chronic conditions that require regular medications. Although religious teachings state that those who are unwell can be exempt from fasting, many patients such as those with diabetes and hypertension feel that they are well and therefore would not include themselves in this category. However the omission of medications and regular meals can cause serious affects.
This was demonstrated by one case from the diabetes clinic. An elderly gentleman attended for follow up. He has type 2 diabetes and normally takes a mixture of short acting and intermediate acting insulin twice daily. He appeared malnourished and unsteady on his feet. His random blood glucose measured very high at 31 mmol/l (normal range 4 - 9 mmol/l). This gentleman, like most of our patients, does not have his own glucometer, as the price of glucose sticks are prohibitively high. In addition at Kivunge we do not have access to tests such as HbA1c which would give us a longer term view of his sugar control. Therefore it can be challenging to interpret these one off blood sugar readings. However on looking back through his record book, his previous attendances in clinic showed blood sugars of 10-20mmol/l over the last year. Therefore this very high reading was an outlier.
From the history it became apparent that he was fasting for Ramadan, despite being on insulin. He was eating a large meal before sunrise, then omitting his morning insulin and fasting throughout the day. He was then occasionally taking his evening dose with food after the break of fast. After examining him and checking his urine for ketones (which was negative) we sat down to discuss a plan. We considered admitting this patient to re-establish an effective insulin regime with regular blood sugar monitoring, however he was very resistant to this. His family had travelled far to be together for Ramadan and there was a lot to be done at home.
We discussed with him that he can be exempt from fasting due to being elderly, diabetic and requiring injection medication. We strongly advised that he return to his normal insulin regime and diet, given the significant risks to his health. This is a difficult conversation that must be done sensitively, as culturally and religiously fasting is very much expected. However the local staff in clinic advised him that he could compensate for not fasting by giving a portion of rice to someone more disadvantaged than himself. We asked him to return to clinic the following week and as he left I was unsure of whether he would follow our advice. However on the next visit, he told us that he had stopped fasting and his blood sugar was better controlled back on insulin.
I have been humbled by our patients ability to fast in Ramadan in this hot country, where living conditions can be challenging and they may not have much food to share around. However it is important to engage in open discussion with patients during this time so that they can make an informed decision and to reduce any stigma for those exempt from fasting. This case highlighted to me the importance of patient education and ensuring patients are aware of the health risks they may be exposed to.