DSA News Spring 2019

DSA Port Elizabeth news

Health awareness day in Malabar


The Malabar Diabetes Wellness Group held their 4th biennial Health Awareness Day, on 22 June 2019, at the Malabar Community Centre.

Amongst the screenings that were offered free of charge to the community were blood glucose, cholesterol, BMI, TB, HIV/AIDS, vision, hearing, and feet examination. A medical doctor was also in attendance to answer questions and offer advice.

Many healthcare groups manned exhibition tables, namely: Port Elizabeth Branch had a display of old glucometers and syringes as well as a slide show of our history; Springdale concentrated on promoting membership; Malabar had a large variety of pamphlets and were there to advise the people; DSA Young Guns explained what is available for young Type 1s; Nelson Mandela Health District; Parkinson’s Support Group; Heart and Stroke Foundation; Van der Sandt Audiology; Retina SA E.C; Specsavers; CANSA; Podiatrist; St Francis Hospice; ForaCare, Africa; and VitolAire.

A total of 192 people took advantage of the various screenings that were on offer. The youngest was a recently diagnosed two-year-old and the oldest an amazing 95-year-old lady.

Before the doors even opened, members of the community were waiting for the free screening tests.
The Nelson Mandela Health District team, led by Sr. Marina Barnard, were in attendance to assist with the screenings.
Surendra Daya and his hard-working committee ladies helped to keep things running smoothly and to ensure that the service providers had ample tasty refreshments.
Paula Thom and Darren Badenhuizen manned the DSA Young Guns table. They helped, not only to give advice to young Type 1s, but also to help people understand that a person of any age can develop diabetes.

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Can people living with diabetes donate blood?

National Blood Donor Month was in June; with that we chat to Dr Nolubabalo Makiwane, from the South African National Blood Services (SANBS) about whether people living with diabetes can donate blood.


  1. Can diabetes patients using insulin (injection or pump) donate blood?

Yes, we accept donors who are using insulin to control their diabetes. Both those using injections or pumps. The most important factor is that their diabetes must be controlled and they must be well on the day they present to donate.

Insulin users should also not have any skin complications associated with using injections/pumps. We won’t allow a donor to donate blood, if they have a skin infection at the injection site, for example.

  1. Can diabetes patients using oral diabetes medication donate blood?

Yes, persons using oral medications and diet to control their diabetes are welcome to donate. Again, their diabetes must be well-controlled and they must be well when presenting to donate blood.

Most medication used to treat diabetes are classed as category B drugs. Therefore, are considered safe if one should opt to become a blood donor.

  • Understanding the categories of medication

Medications are assigned to five letter categories based on their level of risk to foetal outcomes in pregnancy. It can give one a good idea on the level of safety of a drug at a glance. This is of importance in transfusion as a fair percentage of SANBS blood products are used by pregnant women, women in labour or who are post-partum, and, of course, we also supply blood products for use in babies and children.

So, category A is the safest category of drugs to take. Category B medications are medications that are used routinely and safely during pregnancy. The C and D category drugs have shown positive evidence of human foetal risk but potential benefits of the drug may warrant use in pregnant women. Category X is never to be used in pregnancy. This is a classification based on the safety of a drug in pregnancy and lactation.

Pregnancy Category

Description

A No risk in controlled human studies: Adequate and well-controlled human studies have failed to demonstrate a risk to the foetus in the first trimester of pregnancy (and there is no evidence of risk in later trimesters).
B No risk in other studies: Animal reproduction studies have failed to demonstrate a risk to the foetus and there are no adequate and well-controlled studies in pregnant women or animal studies have shown an adverse effect, but adequate and well-controlled studies in pregnant women have failed to demonstrate a risk to the foetus in any trimester.
C Risk not ruled out: Animal reproduction studies have shown an adverse effect on the foetus and there are no adequate and well-controlled studies in humans, but potential benefits may warrant use of the drug in pregnant women despite potential risks.
D Positive evidence of risk: There is positive evidence of human foetal risk based on adverse reaction data from investigational or marketing experience or studies in humans, but potential benefits may warrant use of the drug in pregnant women despite potential risks.
X Contraindicated in pregnancy: Studies in animals or humans have demonstrated foetal abnormalities and/or there is positive evidence of human foetal risk based on adverse reaction data from investigational or marketing experience, and the risks involved in use of the drug in pregnant women clearly outweigh potential benefits.
N FDA has not yet classified the drug into a specified pregnancy category.
  1. What are the medications that if taken, a person can’t donate blood?

Generally, SANBS doesn’t accept donors who are using medication that is classified as teratogenic. These drugs would fall into category X. These medications are known to cause malformations in unborn babies, or miscarriages. These include a lot of dermatological agents, like Roaccutane, Neotigason and etretinate.

Some anticonvulsant medication has been found to have teratogenic effects, such as valproic acid, phenytoin and phenobarbitone.

Some antibiotics and male hormonal medications are also classed as teratogenic. The list of teratogenics is, of course, much longer than this. However, what is of note is that there are no hypoglycaemic agents listed as teratogenic.

  1. Diabetes, unfortunately, has many side effects, such as heart problems, neuropathy, slow-healing, etc. Will any of these side effects stop people living with diabetes from donating blood?

Most definitely. If donors are people living with diabetes and they develop a complication due to their diabetes, we defer them until the complications are resolved, and until good control of the donors’ blood glucose level is re-established.

Persons who suffer from a hypoglycaemic coma (due to low blood glucose levels) are deferred for four months from the time of the episode. This is to ensure that their glucose control is adequate.

SANBS also doesn’t accept donors who develop diabetes as a complication of another disease process. For example, a donor who develops diabetes as a complication of acromegaly (a disorder caused by excessive production of growth hormone by the pituitary gland and marked especially by progressive enlargement of hands, feet, and face) would not be accepted for the procedure.

  1. Does SANBS encourage people living with diabetes to donate blood?

We encourage people living with diabetes to donate blood only if they are well enough to tolerate the procedures. At SANBS, the health of our donors is of very high importance. We do not collect blood from a donor if it would be detrimental to the health of the donor at all. This applies to our diabetic donors, even more so as they are at a slightly increased risk of developing infections and other complications.

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Dr Nolubabalo Makiwane is a registered medical practitioner working in the transfusion medicine field. She is part of the medical team at the SANBS where she works to ensure that donor care is at its best.


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Change in CBD regulation in South Africa

Regulatory experts at Webber Wentzel educate us on the recent change in CBD regulation: if CBD products contain less than 20mg for a daily dose, they will be considered over the counter products.


Constitutional Court ruling

Since the Constitutional Court, in September 2018, effectively decriminalised the possession, use and cultivation of cannabis in private dwellings in South Africa, there has been a rapid surge of cannabidiol (CBD)-containing products on the South African market.

CBD is an active non-psychoactive ingredient within cannabis which cannot make users of the product “high” as is the case with THC. THC is the other ingredient found within cannabis. The reported therapeutic benefits of CBD have resulted in it being featured in products, ranging from wellness, to dog treats and even in your morning smoothie.

The surge in CBD products was also spurred on by the uncertain and difficult regulatory regime that suppliers and distributers found themselves navigating.

Change in CBD regulation: from scheduled substance to OTC

CBD was considered a scheduled substance in terms of the schedules to the Medicines Act. This meant that products that contained CBD and were intended for therapeutic purposes could only be sold by pharmacists to consumers who held a prescription. This view was emphatically publicised by the South African Health Products Regulatory Authority (SAHPRA) in the media.

The Department of Health has since made a turnaround, by creating a significant space for CBD products to be sold to consumers. As of 23 May 2019, all products that contain a maximum daily dose of 20 mg of CBD, and are intended for general health enhancement or relief, are exempted from the operation of the schedules to the Medicines Act.

Arguably, products that fall within this threshold that are intended for therapeutic uses may still be required to register as complementary medicines with SAHPRA. But, once registered, will be capable of being sold directly to a consumer. In other words, CBD products which contain less than 20mg for a daily dose will be considered over the counter (OTC) products and may be sold openly in pharmacies, wellness stores and other outlets.

All products that contain a daily dose of more than 20mg of CBD will still be considered a scheduled substance in schedule 4 of the Medicines Act and would require a prescription to be sold.

Implications for commercial use of new CBD regulation

Notably, all processed products that contain naturally occurring CBD and THC (provided that no more than 0,0075% of the product contains CBD and not more than 0,001% of the product contains THC) may now be sold to consumers without any restrictions.

This change in the CBD regulations has implications for the commercial use of CBD in the manufacture of other products, including foodstuffs and alcohol. Before the recent amendment, consumer products, such as beer brewed from hemp seeds; hemp seed protein; hemp cooking oil; and even flax seeds were classified as scheduled substances by the authorities due the presence of trace amounts of CBD in these products.

The Department of Health’s announcement changes the legal status of these products and removes them from the strict regulation of the Medicines Act. These products may still, however, be subject to other regulatory regimes that govern foodstuffs and liquor.

These changes in the CBD regulations are exciting to the consumer sector and are music to the ears of suppliers of CBD products giving them scope to introduce their products into South Africa more easily. It will be interesting to keep an eye on SAHPRA’s attitude to the changes given that they will no doubt be flooded with registration applications in the coming months.

Exemption applies for one year only

While these changes signify the Department of Health’s relaxation of the regulation of CBD, the exemption applies for one year only. This signals that government is adopting a wait-and-see-approach before committing firmly to a policy position on CBD.

After last year’s Constitutional Court ruling, cannabis will also be squarely on Parliament’s agenda as they have been ordered to make changes to the laws regulating the private use of cannabis. This presents an opportunity for the public’s voices to be heard, not only regarding the private use of cannabis but also in shaping the approach to the commercialisation of cannabis derived products in South Africa going forward.

The recent change to the legal status of CBD, together with the issue of the first three licences to cultivate cannabis for medical use earlier this year by SAHPRA, signals a shifting perspective on the role of cannabis which will hopefully pave the way for the expansion of the cannabis market in South Africa in the near future.

MEET OUR EXPERT


Megan Adderley has experience in judicial review proceedings in the High Courts and litigation relating to municipal powers and functions, providing strategic advice to private sector clients in negotiations with organs of state, preparing and presenting training workshops for local government officials, assisting in drafting the legal aspects of various government policies, advising on co-operative governance responsibilities of various organs of state and conducting due diligence investigations on potential projects and developments. She advises a wide range of clients including all spheres of government and private sector on the administrative and criminal enforcement of environmental, heritage and planning laws. Megan also advises non-profit clients on a wide variety of administrative appeals and reviews, and industry associations on the constitutionality of proposed amendments to legislation.


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Rodney Africa specialises in all matters relating to procurement, local government and general administrative law. He also practices constitutional, public private partnership and general regulatory and compliance law. Rodney has advised clients from both the public and private sectors, and has been involved in various matters relating to procurement, access to information, public decision making, public finance management, the valuation and rating of properties, and all aspects of land use planning and development law. He is an expert in matters involving the public sector and has advised on regulatory matters in a variety of industries. Rodney has extensive experience in litigation in respect of the above areas of law, with a specific focus on judicial review and mandamus applications, tender disputes, interdicts and declaratory relief. He has been a member of the audit committees of various local government departments.


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Deerah Pillay-Lungoomiah focuses on of public and regulatory law, administrative and constitutional law. She also has experience in advising on procurement law related matters. From a regulatory perspective, she has particular expertise in transport, renewables, tourism, tobacco and fishing.


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Adriano Esterhuizen is an expert in procurement, local government law, administrative law and constitutional law. He has extensive experience in dealing with matters relating to property rights, procurement, environmental law, land use planning law, legislation relevant to municipal governance, as well as general statutory and regulatory compliance matters. His services are open to public and private sector clients. He regularly litigates in both the Magistrates’ and High Courts and is able to assist clients with specialist review applications, tender disputes, interdicts and declaratory relief.


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The see-saw of life

Noy Pullen tells us about the see-saw of life when living with diabetes.

When I got the email with the theme, The highs and lows of living with diabetes, for the winter issue of Diabetes Focus, two parts of me start wrestling, like Jacob and the angel – the informed scientific one and the creative artist. One instance of the see-saw of life.

One thing you can learn from the creative process is to use what comes to meet you. The material is not always obvious. You need be awake to possibilities, to recognise the miracle in the day. Or, to use the modern term – be mindful.

The day I got the emailed theme, two things happened which energised me. A radio interview with South African, Paddy Upton, a renowned cricket coach, about his new book: The Barefoot Coach. Something drove me to go and buy his book immediately.

Then came a post on Facebook from a friend whose younger daughter, aptly named Faith, has certain mental and physical difficulties. It read: When she can’t do something, Faith doesn’t say “I got it wrong”, she says, “I’m learning!”

This and Paddy Upton’s use of a quote of T. H. White’s The Once and Future King, where the wizard, Merlin, gives advice, “You may grow old and trembling in your anatomies, you may lie awake at night listening to the disorder of your veins, you may miss your only love, you may see the world about you devastated by evil lunatics, or know your honour trampled in the sewers of baser minds. There is only one thing for it then – to learn…That is the only thing which the mind can never exhaust, never alienate, never be tortured by, never fear or distrust, and never dream of regretting.”, 1showed me my direction for the article. We can learn.

How do we communicate? From autocrat to collaborator

Living or working with diabetes affects everyone nowadays, even if it is only being aware of the dangers of a careless lifestyle.

The current way of giving so-called health education (via recommendations, instructions and advice) when dealing with patients, whether with diabetes awareness, prevention and management, has been found to be ineffective according to many of our participants on the Agents for Change modules.

Comments that are shared are: “The patients are non-compliant.” The term that is used on patient records is defaulter. All health providers are trained in what is called health education. This is a similar model of that of the coach who has the strategies, the answers and the plan that the players need to obey.

Paddy Upton introduces a refreshing possibility of collaboration through questions, self-reflection and opportunities for growth in both the player and the coach. Learning effective ways based on conversations.

Our philosophy was to create an environment that empowered the players to think and decide for themselves. For the players to be able to make good decisions, they needed to become and be treated as the leading experts on their own lives, physical, mental and spiritual. No one knows you better than you do, and sometimes you just need a bit of help in allowing that understanding to emerge from within you.” 1(p103)

When my son, who is living with Type 1 diabetes, had to undergo surgery, his surgeon said to him, “You know your body better than anyone so please advise the surgical team on how your insulin should be administered.” The staff nurse had the same request. An empowering discussion followed and all ended well.

See-saw of patient-focused rather than disease-focused

The individual who has diabetes is not a diabetic, but rather a person with aspirations and unique talents who also happens to be living with diabetes.

It is by unlocking the potential within that the healing becomes reality. So, that people can radiate their individuality, and not just aim for acceptable blood glucose levels. Vibrant health is not absence of disease; it is empowering self-knowledge and the possibility of development.

Upton explains that when one is criticised, the negative emotion causes the body to produce cortisol, triggering a shutdown in thinking. This can cause one to go into conflict or defence mode, and generate unnecessary stress.

The way to manage so-called failure is to view it in terms of a solution in the future – a learning moment. The person can be asked, “When you are faced with a similar situation in the future, what will you do differently?” Possibilities can be explored in relation to the suggestions, offered by both the person and the coach.

See-saw of head-thinking and heart-thinking

There are two kinds of knowing: head-thinking –  the left brain, logical, academic, instructive, outer and scientific aspect. The kind that has the motto: ‘If it can’t be measured, it can’t be managed!’1

Then there is heart-thinking: the inner space, creative, sensing, inspired and intuitive knowing. The kind when you just know something. You have a hunch, or it just feels right.

Why did I go out to by The Barefoot Coach? What does diabetes have to do with cricket? It is not logical. Within the heart-thinking one finds an ‘ear’ amid the word heart. It has to do with subtle listening with every fibre of your being, to find the direction that the moment wants to go. The health provider or loved one of the patient who can practise this kind of sensing/minding will help develop the sense organs for finding the healthy option in any situation – a truly collaborative effort.

Minding or sensing – being in the zone or in flow

Paddy Upton refers to what he calls the small wins. The ones and twos that are often the runs that can make a difference between winning and losing.

Changing micro-habits that you practise daily. Perhaps ,just one eating habit, a small change in physical activity or a decision to meditate, can deliver significant results.

Tick your own tendencies

Look at the lists of the words below. Invite yourself to tick your own tendencies to add to your self-awareness.

These are natural tendencies which we can acknowledge and treasure as bits of self-knowledge. It is not a self-corrective tool, but rather one to make one more aware of your own one-sidedness. Knowing this may help you with managing micro-habits. This may highlight what you are very good at and you could use this when planning a change.

Upton also shares an amusing thought that some of us are born optimists while others veer more to the pessimistic side. According to George Bernard Shaw, both contribute to society, “The optimist invented the airplane and the pessimist invented the parachute.”

Enjoy finding your position on this verbal see-saw. The right side tends toward flair, flamboyance, exaggeration while the left is strict, law-related, rigid, cold or paralysing. In between these extremes are the lessons we are given by life to become more centred.

Optimist                          Realistic                      Pessimistic

Confident                        Present                       Doubting

Artistic                             Intuition                    Scientific

Feeling                              Holistic                      Thinking

License                             Foster                          Instruction

Success                             Practise                       Failure

Win                                   Grow                            Lose

Flattery                             Collaborate                 Criticise

Fun                                   Play                             Rules

Addiction                        Compassion                Violence

Abandon                     Rhythm                       Rigidity

Enjoy finding your special uniqueness and working with that to change what you choose to change. Change is like singing (or cricket). Anyone can do it with a bit of practice and enjoy the see-saw of life.

For information about the Agents For Change project, contact Noy Pullen.


Reference

  • Paddy Upton: The Barefoot Coach LIFE-CHANGING Insights from Coaching the World’s Best Cricketers. Published by Paddy Upton Coaching

Please contact Noy Pullen if you would like more information: linoia@web.co.za or 072 258 7132.


AGENTS FOR CHANGE IS A DIABETES SOUTH AFRICA PROJECT

MANAGED BY NOY PULLEN

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Energy drinks: are they safe?

Energy drinks can be the go-to solution when one is feeling tired. However, are they safe for people living with diabetes? Jessica Pieterse reviewed the latest research and some commonly found energy drinks on the SA market to attain insight.


Caffeine

When most of us think of energy drinks, we assume the caffeine will be sky-high compared to other drinks. Most energy drinks provide an average of 114mg caffeine per standard 455ml can, or 176mg caffeine per the larger 550ml can. This is surprisingly similar to a cup of filter coffee that contains on average 170mg caffeine per 250ml mug.

Though, not all drinks and food fare as closely. A standard 455ml can of energy drink has one and half times the caffeine than a cappuccino (75mg in 250ml) as well as 1,4 times than normal tea (80mg in 250ml), 2,8 to 3,8 times than sweetened fizzy drinks (30 – 40mg in 330ml), and almost 10 times than a chocolate bar (12mg in 40g).

It’s recommended to consume less than 300mg per day of caffeine, or 2,5mg caffeine per kg body weight per day. Meaning a 50kg person should keep caffeine below 125mg/day which is less than one large can of energy drink.

Consuming excessive amounts of caffeine can lead to trouble sleeping, anxiety, irritability, nervousness, rapid heart rate, headaches and dependency on caffeine.

Research behind caffeine consumption in people living with diabetes was surprisingly lacking. The Society for Endocrinology, Metabolism and Diabetes of South Africa (SEMDSA) 2017 guidelines give no mention of caffeine.

Sugar

Energy drinks are consumed often for the caffeine boost, but people living with diabetes should be aware of the sugar contents of these drinks.

Energy drinks that contain sugar and not sweeteners, can offer 11 – 62g of sugar per can which equates to 3 to 16 teaspoons of sugar per can (440 – 550ml). Consuming 16 teaspoons of sugar in one seating would greatly raise blood glucose levels, and regular intake increase HbA1C levels.

We found six energy drinks that offer no sugar as they use sweeteners, such as sucralose, aspartame and acesulfame K. Drinks that use sweeteners will affect blood glucose levels much less. However, avoid large intakes of sweeteners as they may have negative effects on gut functioning.

Vitamins

Energy drink manufactures may use the fact that B vitamins are added as a selling point. B vitamins act as co-factors to support energy processes in the body. A dietary intake that is low in B vitamins can contribute to fatigue. Therefore, B vitamins contribute to boosting energy.

B vitamins are safe for people living with diabetes. People taking long-term Glucophage medication should supplement with vitamin B12. However, most drinks won’t provide sufficient levels of B12 needed. It should be noted that B vitamins are water-soluble and excessive amounts will be urinated out and not stored.

Energy-boosting ingredients

Energy drinks often contain ginseng and guarana. Guarana is a Brazilian plant that has seeds with four times the amount of caffeine found in coffee beans (on a percentage basis), along with other xanthines which also stimulate the central nervous system.

Ginseng comes from a root of a Panax plant. Although manufacturers claim ginseng increases energy and boosts the immune system, evidence is lacking. Ginseng has been shown to interact with immunosuppressive and blood pressure medications and as no warnings appear on the product, this could lead to serious effects. People living with diabetes should therefore, be very careful in taking herbal products as they are often on several medications.

Closing thought

To end things off, I don’t recommend people living with diabetes to consume energy drinks. Mainly due to the high-sugar intake of most drinks. The risk that the added herbal ingredients may also negatively affect medication taken is of great concern.

Caffeine is possibly less of the concern with energy drinks as people living with diabetes can still have high caffeine diets without including energy drinks. However, I would still recommend a safe daily caffeine intake of less than 300mg/day.

These findings are supported by the American Diabetes Association which advocates to avoid energy drinks and rather consume water, unsweetened herbal teas/coffee and milk.

Disclaimer: There is no conflict of interest with the author and any energy drink companies. The dietitian does not work for any companies and there was no payment received from any companies.

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Jessica Pieterse is the director Dish Up Dietitians, Pieterse and Associates and also works at several private hospitals as a part-time locum dietitian, working in the ICU, medical and surgical wards. She has a special interest in nutrigemonics (DNA testing), critical care, weight loss, diabetes, hypercholesteromia, hypertension and gut disorders.


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Ramadan and diabetes: a collaborative approach to fasting

Dr Salim Parker gives a collaborative approach to Ramadan fasting.


One of the five pillars of Islam

Fasting from dawn (the meal in the morning is called Suhoor) to dusk (Iftaar) during the Muslim month of Ramadan is one of the five pillars of Islam. The Quran specifically instructs all mature and healthy Muslims that: “Oh you who believe! Fasting is prescribed to you as it was prescribed to those before you so that you may attain self-restraint.

Most Muslims start fasting from a very young age. Even though, it’s only obligatory when puberty is attained and it is a religious, social and community in most societies. The Islam religion follows the lunar calendar and Ramadan occurs 10 days earlier each successive year. This year (2019) it will be nearly the whole of May.

The sick are allowed to postpone the fast and may even be exempted from it, as stated in the Quran: “Whoever witnesses the month (of Ramadan) then he/she should fast. But, if any of you is ill or travelling – then he or she is exempted from fasting.”

Despite this concession many sick Muslims will fast despite learned religious scholars and medical professionals advising them not to. This applies equally to people living with diabetes and this article outlines some guidelines as to how to approach diabetics intending to fast.

Benefits of fasting

It’s known that there are several potential benefits of fasting during Ramadan. Feelings of compassion for the less fortunate and underprivileged are evoked in Muslims who fast. Though the hunger and thirst senses are heightened, the natural sense to eat or drink is controlled. This leads to a sense of having willpower and to be in control of the senses.

The long-term ideal is for Muslims to ultimately be able to resist daily unnecessary and potentially harmful forms of food as urged by the Quran to: “Eat of what is lawful and wholesome on the earth,’ and ‘And He (God) enforced the balance. That you exceed not the bounds; but observe the balance strictly and fall not short thereof.”

Fasting also offers a time to ‘cleanse’ the body and the soul. The person fasting is encouraged to develop a greater sense of humility, spirituality, and community involvement.

There are also indications of physiological benefits of fasting. Some studies indicate that intermittent fasting limits energy intake. This promotes weight loss in obese individuals, which could be cardio-protective. Insulin sensitivity is also increased.

A holistic approach needed

Currently, of the 366 million humans on earth living with diabetes, more than 50 million are Muslim. In 2015, diabetes was the leading cause of death amongst South African females, and the sixth most frequent one amongst males. Diabetes was the second leading cause of death overall in South Africa after tuberculosis that year.

Many South African Muslims living with diabetes will fast irrespective of their health status. It’s important that there should be synergy between the healthcare professionals, the Islamic scholars and the Muslims living with diabetes who want to fast. Several factors need to be considered:

  • Age of the person
  • Medications used
  • Insulin dependency or not
  • Co-morbidities
  • Recent complications
  • Whether living alone or not
  • Easy access to a glucometer
  • Social support

Lifestyle management

All Muslims living with diabetes should ideally have a pre-Ramadan consultation beforehand with their healthcare practitioner. Fasting and the management of lifestyle conditions go hand in hand and a holistic approach should be adopted.

Dietary intervention is essential and the inclusion of more fibre, complex carbohydrates, vegetables, legumes should be encouraged, as should sparing salt use.

There is increasing evidence that dates, a staple food type during Ramadan, may have beneficial effects on glucose and cholesterol levels during Ramadan and may lead to a decrease in cardiovascular risk factors. Dates, consumes in moderation, are rich in fibre and is high in fructose, which has a lower glycaemic index than sugar.

It’s known that not having breakfast, in the normal population, increases the possibility of being overweight by a factor of five, and increases the chance of developing diabetes. The consumption of the pre-dawn meal is hence paramount. Stopping smoking and optimising of medication and co-morbid conditions should be discussed as well.

Maintaining some form of exercise, such as the optional nightly Ramadan prayers (if possible and depending on level of fitness), is part of lifestyle maintenance.

Complications associated with fasting

Hypoglycaemia

Hypoglycaemia is the concern of most doctors and patients when fasting is contemplated by the Muslim living with diabetes. Several patients, especially the elderly, are not always aware when their glucose levels drop. In one study, 24 out of 29 subjects were not aware that their glucose levels were low.

Different patients will have different signs and symptoms at different levels, with a glucose level below 4 mm/L being dangerous in most instances. Signs are often subtle, such as slight inattentiveness, and may not be easily be picked up by household members. The easy availability of glucometers is paramount in all circumstances and it should be emphasised that checking the levels (finger prick test) does NOT invalidate the fast. If levels are low, the fast should be broken immediately with the religious edict that life and health are MORE important than obligations emphasised.

Hyperglycaemia

Ramadan, contrary to its intention, is associated with caloric excess. An abundance of savouries, pastries and desserts is the norm and people living with diabetes consume as much as others. Hyperglycaemia can thus occur and at times is difficult to distinguish from hypoglycaemia, based on signs and symptoms alone.

The availability of glucometers is thus again important. Patients often fear hypoglycaemia and reduce, or even stop, their medication on their own. Coupled with the dietary excess, the chances of hyperglycaemia are increased and in some countries, such as Pakistan, more cases of hyperglycaemia than hypoglycaemia are seen during Ramadan.

Dehydration

Dehydration, especially if the diabetes is poorly controlled, is a possible complication of fasting during Ramadan. Polyuria (production of abnormally large volumes of dilute urine) and a reluctance to consume too much fluids at night (to avoid urinating) increases the possibility and the development of pre-renal failure, and thrombosis may have to be considered.

Risk categories1 

Category 1: Very High Risk

This include patients with one or more of the following:

  • Severe hypoglycaemia within the three months prior to Ramadan.
  • Diabetic ketoacidosis (DKA) within the three months prior to Ramadan.
  • Hyperosmolar hyperglycaemic coma within the three months prior to Ramadan.
  • History of recurrent hypoglycaemia.
  • History of hypoglycaemia unawareness.
  • Poorly controlled Type1 diabetes mellitus (T1DM).
  • Acute illness.
  • Pregnancy in pre-existing diabetes, or gestational diabetes (GDM) treated with insulin or sulphonylureas.
  • Chronic dialysis or advanced kidney disease.
  • Advanced macrovascular complications.
  • Old age with ill health.

Patients in this category MUST NOT FAST. If they insist on fasting, close monitoring and counselling is essential, with specific instructions given on when they MUST break their fast if necessary. They must be informed that they are putting their health and life at risk.

Category 2: High Risk

In this category are patients with one or more of:

  • T2DM with sustained poor glycaemic control.
  • Well-controlled T1DM.
  • Well-controlled T2DM on MDI or mixed insulin.
  • Pregnant T2DM or GDM controlled by diet only or metformin.
  • Chronic kidney disease stage 3.
  • Stable macrovascular complications.
  • Patients with comorbid conditions that present additional factors.
  • People with diabetes performing intense physical labour.
  • Treatment with drugs that my affect cognitive function.

Patients in this category SHOULD NOT FAST. If they insist on fasting they should also be closely monitored.

Category 3: Moderate/low risk

The following fall in this category:

  • Lifestyle therapy
  • Metformin
  • Acarbose
  • Thiazolidinediones
  • Second-generation Sus
  • incretin-based therapy
  • SGLT2 inhibitors
  • Basal insulin

These patients should be able to fast with sound advice being given first.

Medication adjustment

Each person living with diabetes will have unique circumstances and should be counselled individually. Explaining the risks and symptoms of hypoglycaemia and what appropriate actions to take must be emphasised.

Patients on medication need to be advised to change their dosages to accommodate the daytime fast. Some general guidelines are given below. But, again it must be emphasised that each Muslim who intends fasting must have advice tailored to their unique situation.

Metformin

Metformin has a low-risk of causing hypoglycaemia and generally no dose adjustment is needed. Some authorities advise taking two thirds of the total daily dose with the evening meal, with one third taken with the morning meal. The once-a-day formulation should be taken at the usual dose in the evening.

Sulphonylureas (SU)

The first-generation SUs had a high propensity of causing hypoglycaemia and should be avoided. The second-generation SUs are much safer. The general rule for stable patients living with diabetes is to take half the morning dose and the normal evening dose.

The other option is to switch evening and morning doses and reduce the morning dose. The once-a-day formulation should be taken in the evening, instead of the morning with a halving of the dose for the first few days. The dose can then be adjusted as needed.

Insulin

The dose of basal insulin or once a day premix should initially be decreased by 20% and given in the evening. When basal insulin is given twice a day, the morning dose should be given in the evenings with half the evening dose given in the morning. The same applies to premixes given twice a day. Insulin that is used three times a day should have the midday dose omitted and the morning dose halved. The dosages can then be adjusted as needed.

Other diabetic medications

These generally do not need dose adjustments. Once daily doses should preferably be taken in the evening.

Conclusion

Ramadan is an ideal time for people living with diabetes to implement lifestyle changes that would be in accordance with their religion and improve their health as well as their diabetes control.

Each patient must be consulted well before the commencement of Ramadan and their risks stratified according to their unique circumstances.

Access to glucometers is an important aspect of fasting, as well as knowing who should and should not fast, how and when to test for glucose abnormalities and when to break the fast. A collaborative approach between patients living with diabetes, religious scholars and medical professionals is the ideal approach to ensure the safety of those who want to fast, and to assure those who should not fast that their religion most certainly permits that.

 


Reference:

  1. JEMDSA 2017 Volume 22 Number 1 (Supplement 1) Page 119-136

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Dr Salim Parker is a general practitioner in Elsies River. He is an Honorary Research Associate: Department of Medicine, University of Cape Town and Immediate Past President: South African Society of Travel Medicine (SASTM).