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Ramadan-focused education and awareness in type 2 diabetes

To the Editor: Millions of Muslims across the world fast with complete dedication during the month of Ramadan: this is one of the five main pillars of the Muslim faith. During this month, Muslims fast from dawn to dusk. However, as fasting is not meant to create excessive hardship for an individual, the Koran exempts many people from fasting, including anyone who is ill [1]. Consequently, both religious and medical advice is that generally people with diabetes should not fast, as their metabolic condition could be adversely affected [1, 2]. Of the 14 million Muslims living in Europe [3], the number with diabetes is not known. The majority of Muslim patients with diabetes are passionate about the Ramadan fast but are unaware of the possible complications of fasting, which include hyperglycaemia, hypoglycaemia, and increased risk of dehydration and thrombosis [2, 4]. The Epidemiology of Diabetes and Ramadan (EPIDIAR) study showed that in 13 non-European nations, 79% of Muslim patients with type 2 diabetes fasted for more than 15 days during Ramadan. The study also showed that there was a three- to fivefold increase in the incidence of severe hypoglycaemia during this fasting period [4].

Acknowledging this important group of people with diabetes, the American Diabetes Association (ADA) published a consensus statement in 2005 to address the issues surrounding the management of diabetes during Ramadan [5]. The ADA’s objectives were to invite an open dialogue on this topic, offer a set of medical opinions and suggestions, and identify research topics to answer important medical questions on fasting during Ramadan. The safety of fasting has never been studied in the population of European Muslims with type 2 diabetes, and there is no European Association for the Study of Diabetes (EASD) consensus available for the clinical management of these patients during Ramadan.

We have recently developed a Ramadan-focused structured education and awareness programme in the UK. It was presented at the EASD conference in Rome in 2008 and was awarded the Diabetes Education Study Group prize [6]. Our aim was to meet the unfulfilled patient need for education and thus enable safer fasting for people with diabetes who choose to fast during Ramadan. We evaluated the impact of the programme on weight and hypoglycaemic episodes during Ramadan in a UK Muslim population with type 2 diabetes. There were three main findings for patients who attended the education programme (n = 55): (1) they lost weight (mean 0.7 kg); (2) they were four times less likely to develop hypoglycaemic episodes; (3) they were significantly more empowered to self-manage their diabetes during the month of Ramadan.

We would like to recommend that the EASD or local diabetes societies initiate a working group to develop guidelines and consensus for the management of diabetes in Muslim patients who wish to fast during the month of Ramadan. We hope that the EASD will encourage healthcare providers in Europe to implement an educational programme, as this would not only increase awareness among healthcare providers, but also create an opportunity to study the outcomes of fasting in the European region. The programme that we have developed for the UK is pragmatically designed: hence it is widely applicable, and replicable in the rest of Europe. It could have significant benefits for the Muslim population of Europe affected by diabetes.


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Correspondence to D. Devendra.

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Hassanein, M., Bravis, V., Hui, E. et al. Ramadan-focused education and awareness in type 2 diabetes. Diabetologia 52, 367–368 (2009).

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  • Healthcare Provider
  • American Diabetes Association
  • Severe Hypoglycaemia
  • Awareness Programme
  • Hypoglycaemic Episode