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Attitude of Patients with Diabetes Mellitus toward Fasting Ramadan in Basrah, Iraq

Ramadan is the ninth month of the Muslim calendar, and 1.9 billion Muslims of the world celebrate their holiest month of Ramadan each year. It is the month of fasting in the Muslim calendar when it is believed the Holy Quran (the holy book of Muslims) was sent down from heaven as a guidance unto men a declaration of direction, and a mean of salvation, fasting is one of the five pillars of Islam. Fasting during Ramadan, a holy month of Islam, is an obligatory duty for all healthy adult Muslims [1].


Introduction
Ramadan is the ninth month of the Muslim calendar, and 1.9 billion Muslims of the world celebrate their holiest month of Ramadan each year. It is the month of fasting in the Muslim calendar when it is believed the Holy Quran (the holy book of Muslims) was sent down from heaven as a guidance unto men a declaration of direction, and a mean of salvation, fasting is one of the five pillars of Islam. Fasting during Ramadan, a holy month of Islam, is an obligatory duty for all healthy adult Muslims [1].
It's a lunar-based month, and its duration varies between 29 and 30 days. Its timing changes with respect to seasons. Depending on the geographical location and season, the length of the daily fast may range from a few to more than 20 h. Muslims who fast during Ramadan must abstain from eating, drinking, use of oral medications, and smoking from predawn to after sunset; however, there are no restrictions on food or fluid intake between sunset and dawn [2,3].
Fasting Ramadan increased the risk of both hypoglycemia and hyperglycemia together with diabetic ketoacidosis and dehydration with risk of thrombosis [4].
The diabetes care in Ramadan literature is largely new. The first recommendation was dated back to 2005 [4]. In that recommendation; they avoid the use of the terms "indications" or "contraindications" for fasting because fasting is a religious issue for which patients make their own decision after receiving appropriate advice from religious teachings and their health care providers. However, they emphasize that fasting, especially among patients with type 1 diabetes mellitus (T1DM) with poor glycemic control, is associated with multiple risks. This recommendation was updated in 2016 by International Diabetes Federation (IDF), in collaboration with the Diabetes and Ramadan (DAR) International Alliance [5]. This IDF sponsored guideline was comprehensive and the most representative recommendation for fasting during Ramadan including consultation for the patients and practical recommendation were the Ramadan fasting should not be attempted.
Over the past decade, Ramadan will fall during the summer months in Iraq with the temperature reaching to 50 Celsius at midday, thus increasing the number of fasting hours and raising the risk of adverse effects for diabetic patients wishing to fast.
Disregarding religious beliefs may create a barrier in the global process of cross-cultural therapeutic education. Whether diabetic Muslim patients ask their physicians about fasting and follow their medical advice is unknown [6].

Setting
The study involves patients with diabetes mellitus (DM) who attended the Faiha Specialized Diabetes, Endocrine and Metabolism Center (FDEMC) in Basrah during three months period extending between the March to May 2012(7-9 months after the 2011 Ramadan). The Center is tertiary care receiving patients with diabetes mainly from Basrah.

Design
A cross-sectional study was done on 295 patients with type 2 diabetes mellitus (T2DM) and T1DM who attended the Center for management.

Sampling and sample size
The patient interviewed were diagnosed previously by a specialist, out of the total of 300 diabetic persons who were eligible for the study, five patients refuse to give information about their disease leaving 295 to be included in the study.

The tools of the study
The data relevant to the study purpose were obtained through a particular questionnaire forum prepared by the investigator and approved by the supervisor. The questionnaire has the following nine items: i. Personal characteristic: include name, age, gender, occupation, education.
ii. Type of diabetes and duration.
iii. Type of treatment whether lifestyle, oral antidiabetic drugs (OAD), insulin therapy or both(insulin and OAD).
iv. Type & frequency of OAD and frequency of insulin injection.
v. History of chronic hypertension, myocardial infarction and cerebrovascular accident (CVA).
vi. History of fasted last Ramadan, the number of days fasted, the number of days of the menstrual cycle in the female population.
vii. History of doctor's consultation before the trial of fasting in last Ramadan.
viii. The permission of physicians.
ix. Causes of fasted in last Ramadan (2011), whether for religious cause or to reduce the frequency or stop insulin intake.

Data collection
The researchers visited the FDEMC in Basrah on two selected days per week. For inclusion, patients had to be Muslim with either T1DM or T2DM and able to reply to an oral questionnaire and passed the 2011 Ramadan since the diagnosis of their disease.
Hypertension in diabetic patients was confirmed if systolic BP was equal or more than 140 mmHg and or diastolic BP equal or more than 90 mmHg on two occasions separated by at least one day or more, or on medications for hypertension [7].

Data analysis
The data were coded and analyzed using the statistical package for social sciences (SPSS) for Windows version 15 (SPSS inc. 1995).Quantitative data were presented as means ± standard deviation (SD). Qualitative data were expressed as the frequency.

Results
Patient's characteristics are seen in Table 1. Of 295 patients enrolled in this study, the mean age was 47.36 ± 15.0 years (65.4% females). Of them, 58.0% were a housewife, and 62.0 % had education ≤ six years. Most of our patients were T2DM (82.0%). Only 8.8% of the patients was having duration of diabetes less than one year. Hypertension, myocardial infarction, and CVA were reported in 49.8%, 9.2%, and 5.4% respectively.    The attitude of our patients toward Ramadan is presented in Table 3. Those who fasted last Ramadan were 188 (63.7%) patients. Doctor consultation before fasting was practiced in 133 (70.7%). Of those who consulted their doctors, permission to fast were given only in 46 (34.5%) patients and 87(65.5%) fasted against medical advice. Almost all those who fast were for a religious reason and not to other cause like stop oral medications or insulin.

Discussion
This cross-sectional, population-based study was performed in Basrah (Southern Iraq). To our knowledge, this is the first study on Ramadan fasting in Iraq. Nearly half of our patients were using insulin. Insulin therapy during Ramadan fasting represents a challenge to both patients with T2DM and health care providers alike due to the potential for significant hypoglycemia, albeit this is less frequent (and rarely life-threatening) than that encountered in patients with T1DM [8]. Sixty-two percent of our patients had low education level. High illiteracy rate is barrier for providing the necessary Ramadan-focused diabetes education [9].
Despite the fact that, according to religious rules, Muslims with acute or chronic diseases are exempt from Ramadan fasting, 63.7 % of our diabetic patients fasted during last Ramadan. In France, 51.5% of diabetic inpatients wished to fast during Ramadan [6]. In our study, 45.1% of patients were having consulted their doctors to fast, but 87(65.5%) patients fasted against medical advice. Fasting against physician advice was commonly seen in France study where 53% of patients ignored their doctor's advice, and 35% of patients discussed Ramadan fasting with their GP [6].
In a population-based study(EPIDIAR) conducted across 13 countries revealed adult diabetic Muslims who chose to fast were 78.7% and 42.8% in T2DM and T1DM, respectively [10]. Patients with diabetes usually insist on fasting, often without the approval of their physicians. This insistence may be a reaction against the feeling that due to their disease, they are inferior to other population [11].
Patel et al. found that 99.1% of T2DM opted to fast at one center in Oman [12]. Ghouri et al. [13] showed the positive influence of religious authorities and prominent members of Muslim in encouraging healthcare, such as holding a health fair in a mosque during Ramadan month [13].
When we started the study, our belief was that some patients fasted to reduce the dose of insulin or to stop it, but we could not prove that in this study were almost all patients in this study declare that they fasted Ramadan for a religious reason only.

Study Limitation
Small sample and no details about a number of days fasted in last Ramadan.

Conclusion
Two third of diabetic fasted the last Ramadan. Majority of them consulted their doctor before fast. But two third fasted against medical advice.

Conflict of Interest
None declared.