1. RAMADAN AND CARING FOR THE MUSLIM PATIENT Tasnim Khalife, MD The University of Arizona

2. DISCLOSURES I’m Muslim. Otherwise no disclosures.

3. WHAT IS RAMADAN? A holy month of fasting 9 th month of the lunar calendar lasting 29-30 days In 2015 estimated to be June 18 th -July 17 th (falls during the summer months in the next few years) One of the 5 pillars of Islam and a religious obligation on all healthy adult Muslims Muslims fast from eating, drinking, sexual relations, smoking, and all vices from dawn until sunset

4. WHAT IS RAMADAN? A focus on spiritual and physical well being, discipline, understanding the state of those less fortunate Aim at developing closeness and gratefulness towards God “Ramadan Kareem!” Followed by a celebration called “Eid”

5. WHO IS EXEMPT FROM FASTING? Pre-pubertal children and adolescents Menstruating women, women with postpartum bleeding (absolute exemption) Pregnancy and breastfeeding (women need 30% more calories while breastfeeding!) Disabling mental illness or developmental disabilities Those with acute or chronic illness The traveller The elderly

6. WHY IS IT IMPORTANT FOR PHYSICIANS TO KNOW ABOUT? Estimated 6,000,000 Muslims in America Mostly CA, NY, IL Improve cultural competency Health promotion: encourage patients to continue good habits (i.e. smoking cessation, portion control). Better care for fasting patients with chronic diseases: nutritional advice closer monitoring for high risk patients medication adjustments

8. NUTRITION TIPS FOR FASTING PATIENTS Eat a well-balanced pre-dawn and evening meal during each day of the Ramadan fast. Pre-dawn meal is called suhoor. Evening meal is called iftar. Emphasize complex carbohydrates that release energy more slowly while fasting (e.g. wheat, oats, beans, lentils). Increase fiber-rich foods that digest slowly (e.g. bran, whole-grain cereals, whole-grain bread, fruits) Avoid heavily processed foods and high-glycemic carbs (such as refined flour or sugar, white bread, or white rice)

9. NUTRITION TIPS CONT. Avoid fatty foods. Cook with monounsaturated oils such as olive or canola oil Hydrate, hydrate, hydrate! During non-fasting hours, especially in warmer climates Avoid caffeinated drinks – these act as diuretics Light/moderate exercise is safe during non-fasting hours and they can continue their usual physical activity

10. LET’S FOCUS ON OUR DIABETICS Worldwide, an estimated 40-50 million diabetics fast during Ramadan. 3 43% of those with type-1 and 79% of those with type-2 diabetes fast. 1,3 Estimated 7.5-fold increase in severe hypoglycemia in fasting type-2 diabetics. 3

11. WHAT ARE THE RISKS? If medications are withheld: Hyperglycemia Diabetic ketoacidosis Hyperosmolar hyperglycemic state Dehydration Venous thrombosis. 1,4 If medications are taken w/out dose adjustment: Hypoglycemia Warning signs for these conditions should be given along with instructions to break the fast and seek medical attention if symptoms occur.

12. RISK STRATIFICATION 1

13. DIABETICS WHO FAST NEED CLOSE MONITORING Blood glucose monitoring does NOT nullify the fast Fasting diabetics should be provided with a glucometer to monitor their glucose levels

14. ALGORITHM FOR DIABETES MANAGEMENT 4

15. FASTING IN PREGNANCY Islamic law exempts women who are pregnant or breastfeeding from fasting, however many choose to fast during Ramadan. 5,6 Advise them to hydrate during non-fasting hours Eat a well balanced pre-dawn and evening meal (do not skip the pre-dawn meal!) Recommend alternating days Give precautions against excessive daytime activity Give warning signs that warrant breaking the fast: Decreased fetal movement Extreme fatigue or dizziness Nausea with vomiting

16. I CAN’T GET THAT! I’M FASTING… Eye drops, ear drops - YES Inhalers and nebulizer treatments, nasal sprays – YES (as long as it doesn’t reach the back of the throat) Necessary injections such as immunizations, insulin, and other intramuscular or subcutaneous injections - YES IV fluids – NO (dehydration warrants breaking the fast) Donating blood – NO Oral medications during the fasting hours invalidates the fast so patients often skip mid-day doses. Use long-acting forms or adjust regimens to BID dosing during Ramadan. 2 When in doubt about these or other issues, patients can be advised to consult their local religious leader.

17. REFERENCES 1.Al-Arouj M, Bouguerra R, Buse J, et al. Recommendations for Management of Diabetes During Ramadan. Diabetes Care. 2005;28(9):2305-23. 2.Mughal F. Ramadan: What it means for general practice. Br J Gen Pract. 2014; 64(624):356. 3.Salti I, Be’nard E, Detournay B et al. Results of the Epidemiology of Diabetes and Ramadan Study (EPIDIAR). Diabetes Care. 2004; 27:2306-11. 4.Hui E, Bravis V, Hassanein M, et al. Management of people with diabetes wanting to fast during Ramadan. BMJ. 2010;340:3053. 5.Kridli, SA. Health beliefs and practices of Muslim women during Ramadan. MCN Am J Matern Child Nurs. 2011;36(4):216-221. 6.Josooph J, Abu J, Yu SL. A survey of fasting during pregnancy. Singapore Med J. 2004;45(12):583-586.

18. Questions?