FASTING DURING RAMADAN

Transcription

1 FASTING DURING RAMADAN Dr Neesha Patel University of Manchester 21 st May 2014 Accrington Sponsored by Sanofi

2 Key Objectives By the end of this session you will understand and learn about: Importance of Ramadan in Islam Islamic requirements/exemptions for fasting Clinical guidance on medication during fasting Pre Ramadan consultations and patient education Safe fasting practices for patients who wish to fast Patients beliefs about fasting during Brief exercise to evoke beliefs and intensions to fast Summary and key messages

3 What is Islam? Islam is the second largest religion in the world Islam: surrendering your will to God (Allah) Believing that there is one God Following his guidance enjoying what is good and preventing what is bad in yourself and around you Practicing the Islamic rituals Ramadan

4 9th WHAT IS RAMADAN?

5 Fasting during Ramadan Key facts: Fasting during Ramadan is obligatory upon each sane, responsible and healthy Muslim Abstain from food, drinks, smoking, sexual activity from sunrise until sunset Fasting is believed to teach moral, self discipline and sympathy for the poor

6 Fasting during Ramadan In the UK winter months a fast can last up to 9 hours and in the summer up to 19 hours Most Muslims will eat 2 meals, once before sunrise (sehar) and one after sunset (Iftar)

7 Behaviours which do not break the fast Blood tests do not invalidate the fast Medications absorbed through the skin Gargling (as long as no liquid is swallowed) Cleaning the teeth Injections Eating or drinking by mistake Inhalers Eye and eye drops

8 Exemptions from fasting Pregnant and breastfeeding Menstruating women The old and frail Travelling a distance >50 miles Cognitive impairments/learning difficulties Children under the age of puberty Sick fasting may be detrimental to health Give money or food to the poor (redemption)

9 Diabetes and Ramadan

10 Diabetes Diabetes is six times more common in the UK South Asian population (Diabetes UK, 2012) More common in the UK Muslim population (Diabetes UK, 2012) 2.7 Muslims in the UK, 4.8% of the population; 350,000 UK Muslims have type 2 diabetes Multi factorial (e.g. diet, lack of physical activity, language barriers, socioeconomic status, poverty) Difficulties with self management (Pardhan & Mahomed (2004) Poorer health outcomes (Nazroo, 2009)

11 Fasting during Ramadan Personal choice Influenced by cultural and social norms Religious beliefs tensions (Patel et al, 2014) May still need practical advice on: Whether to observe the fast Changing lifestyle behaviours (e.g. diet) How to monitor blood sugar levels during fasting Risks of fasting

12 Risks of fasting Type 1: Ketoacidosis Hyperglycemia absence of insulin Type 2: Hypoglycemia Dehydration

13 General Advice Advice to monitor blood glucose regularly Patients should break their fast if: Blood glucose < 3.5mmol Blood glucose > 16mmol Blood glucose < 3.9 in the morning if the patient is on insulin or sulphonylurea

14 EPIDAIR Study EPIDAIR Study largest study on fasting and diabetes during Ramadan (Salti et al, 2004) 13 countries, 12, 243 participants 8.3% type 1 diabetes; 86.5% type 2 diabetes 43% with type 1 and 79% with type 2 reported fasting for at least 15 days

15 EPIDIAR Study Fasting and hypoglycemia Increased 5 fold in type 1; 3 fold in type 2 Fasting and hyperglycemia Increased 3 fold in type 1; 5 fold in type 2 Reasons alterations, reduction in medication Poor baseline glycemic control Use of basal bolus regimen using insulin analogues and insulin pump, test sugars regularly > successful in type 1 diabetes (Karamat et al, 2010)

16 Risk Stratification Developed by a team of international diabetes clinicians (Hui et al, 2010) Identify patients high, moderate and low risk Recommend intensive structured education programmes Reduce the risks of fasting

17 Risk Stratification High risk Renal insufficiency Other co morbidities Moderate hyperglycemia HbA1c 7.5 9% Macro vascular complications Moderate risk Well controlled type 2 treated with short acting insulin secretagogues Low risk Well controlled type 2 treated with diet, metformin, glitazone, incretin based therapy, SGLT2i therapy

18 Management of diabetes during Ramadan

19 Medical Assessment Patients are advised to contact their nurse or doctor for a full medical assessment 1 2 months prior to Ramadan Identify patients intension to fast individual Review/adjust medication Hui et al, 2010

20 Structured education Patient and family members Risks of fasting Provide opportunity to change other behaviours (e.g. smoking, diet) Help people to fulfill their spiritual needs if they cannot fast Hui et al, 2010

21 Management of Type 1 diabetes General advice for patients with type 1 is not to fast Risks of fasting should be explained Medication regime If the patients wish to fast they should: Be on basal bolus with insulin analogues (Hui et al, 2010) Test their blood sugars regularly Break their fast if their blood sugar <3.5 or > 16mmol

22 Management of Type 2 diabetes Risk of fasting should be explained Consultant clinical guidelines for changes to medication

23 Source: Hui et al, 2010 An approach to oral treatment of type 2 diabetes during Ramadan for patients planning to fast

24 Dietary advice Two meals per day sunset and sunrise Fast is broken with dates, water, milk or fruit Patients should be advised to: Eat foods high in fiber and slow energy foods before and after fasting Foods high in saturated fats (e.g. samosa, pakora) should be consumed in moderation Drink plenty of water, sugar free drinks and decaffeinated drinks to avoid dehydration

25 Physical activity Normal levels of activity are encouraged Avoid any rigorous exercise > reduce the risk of hypoglycemia (Al Alrouj et al, 2010) Tradition to walk to the mosque after breaking the fast with a snack to attend evening prayers Praying involves standing, bowing for up to 1.5 hours Delay taking blood glucose lowering therapy until after returning from prayers (Mugal, 2011)

26 Question: Does this happen in practice?

27 Answer: We don t know!

28 Barriers to pre Ramadan consultations Identifying patients who fast Ethnicity records Comfort and confidence Skills and Knowledge to initiate discussion

29 What are patients experiences of fasting and access to care during/for Ramadan?

30 Patient experiences of fasting during Ramadan

31 Patient experiences of fasting during Qualitative study Ramadan Semi structured interviews 23 Muslim people Greater Manchester Study Aims: Beliefs and experiences of diabetes management during Ramadan Role of the GP or Practice Nurse during fasting

32 Key Findings Main themes Normalising diabetes The significance of fasting Guilt of fasting Pressure to fast from the family Reluctance to disclose fasting to GP/PN

33 Sample Characteristics Total 23 Muslim Respondents (n) (%) Gender Male Female Age (mean = 52, SD = 12) Diabetes Type 1 Type 2 Respondents reported to fast Type 1 Type 2 Medication Oral Insulin injections

34 NORMALISING DIABETES It s okay because these days everyone has diabetes [laugh]...if it was like I d never heard of it, I d think, oh what s happening, am I going to die... because my immediate family had it, it wasn t that much of a surprise [42 year old male, T1DM] We just put it down to being in the family because my Dad had it [53 year old female, T2DM]

35 THE SIGNIFICANCE OF FASTING For Muslim people, it is vital to fast. Yes I am ill but my faith keeps me strong and if I am going to get worse health-wise I am going to get worse no matter what Normally I have to take my tablets once in the morning and once in the evening if feel my sugar is high or very low then I take one in the morning before breakfast otherwise I just take it at night (43 year old female, T2DM) Allah helps us loads, it doesn't t make any difference. You feel very fresh, very happy, and very calm (45 year old female, T2D)

36 GUILT OF NOT FASTING I feel guilty.i ve spoken to a few patients that do Ramadan and they ve said the same thing, that they feel really guilty when they don't fast, even though they give money abroad for the family. But it s still the inner feeling like I feel like I m not doing the right thing by my religion and my beliefs. (54 year old female,t2dm) I do feel guilty about it, especially at the beginning I did really sort of...i used to fast from the age of 5 and I have been fasting until I started on the insulin. I just feel like you can t do what you re supposed to do as part of your religion, and I definitely feel guilty. [43 year old female, T2DM]

37 FAMILY PRESSURE He [patient] doesn t fast now. Our Ramadan is coming up and he can still fast but for the past two years he s not been fasting and I don t think it s an option, he should do fasting. (Wife of a 47 year old male, T2DM) My sugars get low (55 year old male, T2DM) Well it s all in his head, he thinks that if he fasts that his sugar will go low but he doesn t want to so I know they are going back and fasting times are longer but still if a kid can manage he can manage. I mean my Dad can manage it, his a diabetic, all the old diabetic people can manage it (Wife of a 47 year old male,t2dm)

38 RELUCTANCE TO DISCLOSE I don t bother to tell my GP. My doctor never advices anything for Ramadan even though my doctor is a Muslim doctor himself. I am really surprised about this. I am not very happy with my doctor. [38 year old male, T2D] In that month I never go to the doctor that one month I feel fine [laugh]. If I am not well, I still don t go because they will tell me not to fast. (69 year old, female, T2D)

39 I ve not openly told her that I fast, but she knows I am Muslim she should tell me. I can t remember if she has told me anything but maybe she is thinking it s not something that is good for health but as a doctor...she knows but she doesn t say anything [45 year old female, T2DM] I ve discussed it with my nurse and she said, the choice is yours, but you ve got your medication. She pointed out that I will have long gaps. I never really know how it s going to affect me... even though I ve asked them they say it s my choice [54 year old female, T2DM ] GPs have always said don t fast. I suppose if they are not from that cultural background they won t understand it anyhow. To them it s what you ve got to do for your health, but with me when I was on the tablets I felt okay fasting and they were shorter around that time. [43 year old female, T2DM]

40 Why is this important?

41 Linking thoughts & feelings with behaviour Thoughts Behaviour Feelings Thanks to Chris Bundy

42 Cognitive Behavioural model Thanks to Chris Bundy

43 Benefits of eliciting beliefs Important aspect of offering a holistic approach to their care May help to address particular treatment beliefs improve adherence, understanding, increase activation in their own management Inform behaviour change

44 Summary of the findings Religious beliefs > fasting behaviours (+ ) Psychosocial effects of fasting Personal achievement, sense of identity and belonging Reinforce fasting behaviours Alter medication and diet Without disclosing to GP/Practice Nurse Serious consequences

45 Key messages Fasting during Ramadan is an important ritual in the Islam religion Ramadan provides many challenges for both patients and healthcare professionals Talking about fasting in consultation is important to identify patients intentions to fast > ensure safe practice > reduce future complications Work with local Imams > support and guidance in accordance with the Quran

46 Further Reading and Resources NHS Berkshire. Diabetes and fasting in Ramadan. Available at: anhome.aspx Ramadan and your Diabetic patient: A resource pack for Healthcare Professionalshttp://library.nhsggc.org.uk/mediaAssets/My%20HSD / RAMADAN_RESOURCE_PACK.pdf Ramadan Health Guidehttp://

47 References Al Arouj M, Assaad Khalil S, Buse J et al. Recommendations for management of diabetes during ramadan: update Diabetes Care, 2010; 33: Diabetes in the UK 2012 (April 2012) Key statistics on diabetes: the uk 2012 Hui E, Devendra D. Diabetes and fasting during Ramadan. Diabetes Metabolism Research and Reviews, 2010; 26: Karamat MA, Syed A, Hanif W. Review of diabetes management and guidelines during Ramadan. Journal of Royal Society of Medicine, 2010; 103: Mughal S. Preparing Muslims with diabetes for Ramadan. Journal of Diabetes Nursing, 2011; 15: Nazroo, J. Y., Falaschetti, E., Pierce, M. and Primatesta, P. (2009) 'Ethnic inequalities in access to and outcomes of healthcare: analysis of the Health Survey for England', Journal of Epidemiology Community Health, 63(12), pp Pardhan, S. and Mahomed, I. (2004) Knowledge, self help and socioeconomic factors in South Asian and Caucasian diabetic patients, Eye, 18 (5), pp Patel N.R, Kennedy A, Rogers A, Blickem, C, Reeves D, Chew Graham C. "I have diabetes and I fast". Beliefs about fasting during Ramadan in the South Asian population with diabetes: a qualitative study. Health Expectations, 2014; DOI: /hex Salti I, A population based study of diabetes and its characteristics during the fasting month of Ramadan in 13 countries: results of the epidemiology of diabetes and Ramadan 1422/2001 (EPIDIAR) study. Diabetic Care, 2004; 10,

48 Thank you for listening Questions? neesha.patel

49 Discussion What are the barriers to supporting Muslim patients who wish to fast in your practice and/or consultation? What current techniques (if any) do you use to elicit patients beliefs or intentions to fast?

50 A technique to evoke intensions, beliefs and fasting behaviours in consultation

51 Agenda setting

52 Two agendas Yours The patient s

53 Shared decision making Your expertise Patient s experience

54 What to do Managing expectations & agreeing the agenda Tell them about how you tend to work, what you d like to get out of the session, and how long you ve got Ask them what they would like to get out of the session Offer them a menu of things they may wish to talk about Get started Why do this? Develop the partnership / therapeutic alliance Give the patient a sense of control over the conversation Communicate expectations May reduce resistance and defensiveness Help you get things covered Thanks to Chris Bundy

55 Focusing chart weight Physical Activity and fasting medication Fasting and Ramadan Diet and fasting Smoking Thanks to Tim Anstiss

56 Sample Script What it sounds like Now we have about 10 minutes together today And what I would like to do is get a better understanding of X, and talk with you a little bit about Y How does that sound? To start with I would really like to know what you would like to get out of this conversation/session Here are some of the things that other people like to talk about with me in consultation [show them the focusing chart] Which of these would you most like to talk about? And I ve left some blank in case there is something that you would like to talk about with me that is not on this list What would make this session most helpful from your perspective? Thanks to Chris Bundy

57 Exercise 1. In pairs decide who is going to the patient and who is going to be the nurse or GP 2. Use the blank Focusing Chart to: Prior to the consultation, write in the blank spaces the key things you (nurse/gp) would like to focus on in consultation, leaving some blank spaces for the patient. 3. Use the same focusing chart to structure the consultation and write down in the blank spaces the key things the patient would like to focus on in today s consultation.

58 Style: that of a guide! licit: what patient knows rovide: information licit: what patient thinks, feels, might do 58 Thanks to Chris Bundy

59 Agreeing a plan Get behavioural Agree behaviours to reach goals Agree how often, how much, when, with who, what help might be needed, etc. Ask about problems that may be encountered Ask about ways round problems Ask what help / support they might need Thanks to Chris Bundy

60 The expert trap Thanks to Chris Bundy

61 Information sharing using A S A Ask What do you know about the risks of fasting for people with diabetes? Them Ask Can I share with you what we now think? You Would it be ok if I share with you what other people find helpful? Can I tell you what we tend to recommend in this clinic? Share We tend to find people who to X tend to get less Y Other people find the following things helpful... We usually recommend people X, since that helps them Y Sometimes people on this drug tend to notice X, and that can sometimes lead to Y Ask What do you make of what I ve just said? Thanks to Chris Bundy

62 Sharing information Choose a topic with your partner A patient / a professional / an observer The professional follows the A S A process for delivering and sharing the information The observer pays attention to the flow of the professional and counts 3 sentences told by the professional. After this 3 rd sentence, he touches gently the professional s shoulder who will have to stop his intervention by asking the patient s opinion (or what he finds relevant to ask) Thanks to Chris Bundy

63 Sample focusing chart Thanks to Tim Anstiss