•  Fasting & Health

Abstract :It is a globally recognized and foremost part of dietary guidelines that eating a variety of food using principles of moderation and balance. This is particularly true during the Islamic month of Ramadan when Muslims fast from dawn to sunset. To be healthy, one must consume food from the major food groups: bread and cereal, milk and dairy product, meat and bean, vegetable and fruit. During the month long fast of Ramadan the metabolic rate of a fasting person slows down and other regulatory mechanisms start functioning. Body and dietary fat is efficiently utilized. Consuming total food intake that is less than the total food intake during normal days is sufficient to maintain a person's health. Intake of fruits after a meal is strongly suggested. A balanced diet improves blood cholesterol profile, reduces gastric acidity, prevents constipation and other digestive problems, and contributes to an active and healthy life style. (Int. J. Ramadan Fasting Research, 3:1-6, 1999)

INTRODUCTION

Fasting during the Islamic month of Ramadan can be good for one's health and personal development. Ramadan fasting is not just about disciplining the body to restrain from eating food and drinking water from predawn until sunset. The eyes, the ears, the tongue, and even the private parts are equally obligated to be restrained if a Muslim wants to gain the total rewards of fasting. Ramadan is also about restraining anger, doing good deeds, exercising personal discipline, and preparing oneself to serve as a good Muslim and a good person during and after Ramadan.

This is why the Messenger of Allah (Peace be upon him, Pbuh) has been attributed, by Hazrat Abu Hurairah in hadith, to say: "He who does not desist from obscene language and acting obscenely (during the period of fasting), Allah has no need that he didn't eat or drink." (Bukhari, Muslim). In another hadith by Hazrat Abu Harairah, the Prophet (Pbuh) said: "Fasting is not only from food and drink, fasting is to refrain from obscene (acts). If someone verbally abuses you or acts ignorantly toward you, say (to them) 'I am fasting; I am fasting." (Ibn Khuzaoinah). Restraint from food, water, and undesirable behavior makes a person more mentally disciplined and less prone to unhealthy behavior. In an investigation in Jordan (1), a significant reduction of parasuicidal cases was noted during the month of Ramadan. In the United Kingdom , the Ramadan model has been used by various health departments and organizations to reduce cigarette smoking among the masses, especially among Africans and Asians (2).

Ramadan fasting has spiritual, physical, psychological, and social benefits; however, manmade problems may occur, if fasting is not properly practiced. First of all, there is no need to consume excess food at iftar (the food eaten immediately after sunset to break fast), dinner or sahur ( the light meal generally eaten about half an hour to one hour before dawn). The body has regulatory mechanisms that activate during fasting. There is efficient utilization of body fat, El Ati et al. (3) . Basal metabolism slows down during Ramadan fasting, Husain et al. (4). A diet that is less than a normal amount of food intake but balanced is sufficient enough to keep a person healthy and active during the month of Ramadan.

Health problems can emerge as a result of excess food intake, foods that make the diet unbalanced, and insufficient sleep (5, 6). Ultimately also, such a lifestyle contradicts the essential requirements and spirit of Ramadan.

DIET DURING RAMADAN

According to Sunna (the practices of Prophet Muhammad, Pbuh) and research findings referred in this report, a dietary plan is given:
1. Bread/Cereal/Rice, Pasta, Biscuits and Cracker Group: 6-11 servings/day;
2. Meat/Beans/ Nut Group: 2-3 servings/day.
3. Milk and Milk Product Group: 2-3 servings/day.
4. Vegetable Group: 3-5 servings/day;
5. Fruit Group: 2-4 servings/day.
6. Added sugar (table sugar, sucrose): sparingly.
7. Added fat, polyunsaturated oil 4-7 table spoons.

Breakfast, iftar:
1. Dates, three
2. Juice, 1 serving (4 oz.)
3. Vegetable soup with some pasta or graham crackers, 1 cup

The body's immediate need at the time of iftar is to get an easily available energy source in the form of glucose for every living cell, particularly the brain and nerve cells. Dates and juices are good sources of sugars. Dates and juice in the above quantity are sufficient to bring low blood glucose levels to normal levels. Juice and soup help maintain water and mineral balance in the body. An unbalanced diet and too many servings of sherbets and sweets with added sugar have been found to be unhealthy, Gumma et al. (7).

Dinner:

Consume foods from all the following food groups:

1. Meat/Bean Group: Chicken, beef, lamb, goat, fish, 1-2 servings (serving size = a slice =1 oz); green pea, chickpea (garbanzo, chana, humus), green gram, black gram, lentil, lima bean and other beans, 1 serving (half cup). Meat and beans are a good source of protein, minerals, and certain vitamins. Beans are a good source of dietary fiber, as well.

2. Bread/Cereal Group: Whole wheat bread, 2 servings (serving size = 1 oz) or cooked rice, one cup or combination. This group is a good source of complex carbohydrates, which are a good source of energy and provide some protein, minerals, and dietary fiber.

3. Milk Group: milk or butter-milk (lassi without sugar), yogurt or cottage cheese (one cup). Those who can not tolerate whole milk must try fermented products such as butter-milk and yogurt. Milk and dairy products are good sources of protein and calcium, which are essential for body tissue maintenance and several physiological functions.

4. Vegetable Group: Mixed vegetable salad, 1 serving (one cup), (lettuce, carrot, parsley, cucumber, broccoli, coriander leaves, cauliflower or other vegetables as desired.) Add 2 teaspoons of olive oil or any polyunsaturated oil and 2 spoons of vinegar. Polyunsaturated fat provides the body with essential fatty acids and keto acids. Cooked vegetables such as guar beans, French beans, okra (bhindi), eggplant (baigan), bottle gourd (loki), cabbage, spinach, 1 serving (4 oz). Vegetables are a good source of dietary fiber, vitamin A, carotene, lycopenes, and other phytochemicals, which are antioxidants. These are helpful in the prevention of cancer, cardiovascular diseases, and many other health problems.

5. Fruits Group: 1-2 servings of citrus and/or other fruits. Eat fruits as the last item of the dinner or soon after dinner, to facilitate digestion and prevent many gastrointestinal problems. Citrus fruits provide vitamin C. Fruits are a good source of dietary fiber. Fruits and mixed nuts may be eaten as a snack after dinner or tarawiaha or before sleep.

Pre-dawn Meal (sahur):

Consume a light sahur. Eat whole wheat or oat cereal or whole wheat bread, 1-2 serving with a cup of milk. Add 2-3 teaspoons of olive oil or any other monounsaturated or polyunsaturated fats in a salad or the cereal. Eat 1-2 servings of fruits, as a last item.

DISCUSSION

Blood cholesterol and uric acid levels are sometimes elevated during the month of Ramadan (8). Contrary to popular thinking, it was found that intake of a moderately high-fat diet, around 36% of the total energy (calories), improved blood cholesterol profile, Nomani, et al. (9) and Nomani (10). It also prevents the elevation of blood uric acid level (8-10). The normal recommended guideline for fat is 30% or less energy. On weight basis, suggested fat intake during Ramadan is almost the same as at normal days. Fat is required for the absorption of fat-soluble vitamins (A, D, E, K) and carotenoids. Essential fatty acids are an important component of the cell membrane. They also are required for the synthesis of the hormone prostaglandin. Keto-acids from fat are especially beneficial during Ramadan to meet the energy requirement of brain and nerve cells. Keto-acids also are useful in the synthesis of glucose through the metabolic pathway of gluconeogenesis. This reduces the breakdown of body proteins for glucose synthesis. Therefore, the energy equivalent of 1-2 bread/cereal servings may be replaced with polyunsaturated fat.

During Ramadan increased gastric acidity is often noticed, Iraki, et al. (5), exhibiting itself with symptoms such as a burning feeling in the stomach, a heaviness in the stomach, and a sour mouth. Whole wheat bread, vegetables, humus, beans, and fruits -- excellent sources of dietary fiber -- trigger muscular action, churning and mixing food, breaking food into small particles, binding bile acids, opening the area between the stomach and the deudenum-jejunum and moving digesta in the small intestine, Kay (11). Thus, dietary fiber helps reduce gastric acidity and excess bile acids, Rydning et al. (12). In view of dietary fiber's role in moving digesta, it prevents constipation. It's strongly suggested that peptic ulcer patients avoid spicy foods and consult a doctor for appropriate medicine and diet. Diabetic subjects, particularly severe type I (insulin dependent) or type II (non-insulin dependent), must consult their doctor for the type and dosage of medicine, and diet and precautions to be taken during the month. Generally diabetes mellitus, type II, is manageable through proper diet during Ramadan, Azizi and Siahkolah (13).

Pregnant and lactating women's needs for energy and nutrients are more critical than the needs of men (14). There is a possibility of health complications to the pregnant woman and the fetus or the lactating mother and the breastfed child, if energy and nutrient requirements are not met during the month of Ramadan (15-19). Governments, communities, and heads of the family must give highest priority to meet women's dietary needs. In African countries, Bangladesh , India , Pakistan and many other places malnutrition is a major problem, especially among women from low-income groups. Further more, it is common among these women to perform strenuous work on farms or in factories, and other places. Malnutrition and strenuous conditions may lead to medical problems and danger to life. Under these conditions one must consult a medical doctor for treatment and maulana or shiekh for postponement or other suggestions regarding fasting. Quran Al-Hakeem and Hadith allow pregnant women and lactating mothers flexibility during the month of Ramadan.

For practical purposes and estimation of nutrients a diet was formulated, given below:

Iftar: 3 dates, 1/2 cup of orange juice, 1 cup of vegetable soup, 2 plain graham crackers; dinner: 1 cup of vegetable salad with two teaspoons of corn oil and two teaspoon of vinegar, 2 oz. of chicken, 1/2 cup of okra, 4 oz. of cooked whole chana (garbanzo), 3 tea spoon of oil while cooking main dishes, 2 slices of whole wheat bread, 1 cup of cooked rice, 3/4 cup of plain yogurt, one orange, 1/2 cup grapes, 1 oz of nuts-mixed roasted-without salt; sahur: 2 slices of whole wheat bread, 1 cup of milk, 1/4 cup of vegetable salad with two teaspoons of corn oil and two teaspoons of vinegar, 1 skinned apple, 2 teaspoons of sugar with tea or coffee.

Nutritionist IV (20) was used to estimate energy and nutrient content in the above diet, which was as follows: energy, 2136 kilocalories; protein, 70g; carbohydrate , 286g; fat, 87g, 35 % of energy of the total intake, (saturated fat 16.9g; mono saturated, 28.4g; poly unsaturated, 34g; other 7.3g; - oleic, 25.6g; linoleic, 29.5; linolenic, 0.6g; EPA-Omega-3, 0.006g; DHA-omega-3, 0.023g; dietary fiber 34g; calcium, 1013mg; sodium, 3252 mg; potassium, 2963mg; iron 13.3mg; zinc, 10mg. When the nutrients were compared with the Recommended Dietary Allowance (RDA), for an adult non-pregnant and non-lactating female (14), the diet met 100% or more of the RDA for protein, calcium, sodium, potassium, and vitamin A, K, B1, B2, B3, B6, B12, folate, and C. The energy was close to the RDA, (97%). The dietary fiber level also was met as per the recommendation (11). Consuming food in the above amount by pregnant or lactating female may not meet the RDA for all of the nutrients. They may need supplementation of some minerals and vitamins such as, iron vitamin D, and more energy through bread or rice.

Further suggestions:

•  Drink sufficient water between Iftar and sleep to avoid dehydration.

•  Consume sufficient vegetables at meals. Eat fruits at the end of the meal.

•  Avoid intake of high sugar (table sugar, sucrose) foods through sweets or other forms.

•  Avoid spicy foods.

•  Avoid caffeine drinks such as coke, coffee or tea. Caffeine is a diuretic. Three days to five days before Ramadan gradually reduce the intake of these drinks. A sudden decrease in caffeine prompts headaches, mood swings and irritability.

•  Smoking is a health risk factor. Avoid smoking cigarettes. If you cannot give up smoking, cut down gradually starting a few weeks before Ramadan. Smoking negatively affects utilization of various vitamins, metabolites and enzyme systems in the body.

•  Do not forget to brush or Miswak (tender neem tree branch, Azhardicta indica or other appropriate plant in a country, about 1/4-1/2 inch diameter and 6-8 inches length, tip partially chewed and made brush like). Brush your teeth before sleep and after sahur. Brush more than two times or as many times as practicable.

Normal or overweight people should not gain weight. For overweight people Ramadan is an excellent opportunity to lose weight. Underweight or marginally normal weight people are discouraged from losing weight. Analyzing a diet's energy and nutritional component, using food composition tables or computer software, will be useful in planning an appropriate diet.

It is recommended that everyone engage in some kind of light exercise, such as stretching or walking. It's important to follow good time management practices for Ibada (prayer and other religious activities), sleep, studies, job, and physical activities or exercise.

In summary, intake of a balanced diet is critical to maintain good health, sustain an active lifestyle and attain the full benefits of Ramadan.

Abstract : The objective of this review article is to assist physicians who face the difficult task of advising diabetic patients about the safety of fasting during the Islamic month of Ramadan. There have been diverse findings regarding the physiological impact of Ramadan on diabetics. However, researchers have not found pathological changes or clinical complications in any of the following parameters in diabetics who fast: body weight, blood glucose, HbA1C, c-peptide, insulin, fructoseamine, cholesterol and triglycerides. In the guidelines section of the article, we strongly recommend diabetic patients continue their regular daily activity and diet regimen. It is also critical that diabetics adjust their drug treatments, particularly those patients diagnosed with insulin dependent diabetes mellitus (IDDM). We named these three important factors -- drug regimen adjustment, diet control and daily activity -- the "Ramadan 3D Triangle." With 3D attention, proper education and diabetic management, we conclude that most non-insulin dependent diabetes mellitus (NIDDM) patients and occasional IDDM patients who insist on fasting can carefully observe Ramadan. Int J Ramadan Fasting Res. 2:8-17, 1998.

INTRODUCTION

Several of the world's great religions recommend a period of fasting or abstinence from certain foods. Of these, the Islamic fast during the Muslim month of Ramadan is strictly observed every year. Islam specifically outlines one full month of intermittent fasting. The experience of fasting is intended to teach Muslims self-discipline and self-restraint and remind them of the plight of the impoverished. Muslims observing the fast are required to abstain not only from eating and drinking, but also from consuming oral medications and intravenous nutritional fluids.

The month of Ramadan contains 28 days to 30 days. The dates of observance differ each year because Ramadan is set to a lunar calendar. Fasting extends each day from dawn until sunset, a period which varies by geographical location and season. In summer months and northern latitudes, the fast can last up to 18 hours or more. Islam recommends that fasting Muslims eat a meal before dawn, called "sahur." Individuals are exempt from Ramadan fasting if they are suffering from an illness that could be adversely affected by fasting. They are allowed to restrain from fasting for one day to all 30 days, depending on the condition of their illness. People diagnosed with diabetes fall into this category and are exempt from the fasting requirement, but they are often loathe to accept this concession. Physicians working in Muslims countries and communities commonly face the difficult task of advising diabetic patients whether it is safe to fast, as well as recommending the dietary and drug regimens diabetics should follow if they decide to fast. The lack of adequate literature on this subject makes it difficult to answer these questions. To judge correctly whether to grant medical permission to fast to a diabetic patient, it is essential physicians have an appreciation of the effect of Ramadan fasting on the pathophysiology of diabetes mellitus. In this article, we first review principles of carbohydrate metabolism and alterations of certain biochemical variables in diabetics observing Ramadan fasting. We then overview current medical recommendations that allow certain diabetic patients to fast and outline terms for diabetic patients, particularly IDDM patients, who should not fast but insist on fasting.

THE PHYSIOLOGICAL STATE OF DIABETICS DURING RAMADAN

Carbohydrate metabolism during Ramadan fasting in healthy persons

The effect of experimental short-term fasting on carbohydrate metabolism has been extensively studied (1,2). It has been uniformly found that a slight decrease in serum glucose to 3.3 mmol to 3.9 mmol (60 mg/dl to 70 mg/dl)occurs in normal adults a few hours after fasting has begun. However, the reduction in serum glucose ceases due to increased gluconeogenesis in the liver. That occurs because of a decrease in insulin concentration and a rise in glucagon and sympathetic activity (3). In children aged one years to nine years, fasting for a 24-hour period has caused a decrease in the blood glucose to half of the baseline figure for normal children of that age group. In 22% of these children, blood glucose has fallen below 40 mg/dl (4). Few studies have shown the effect of Ramadan fasting on serum glucose (5-9). One study has shown a slight decrease in serum glucose in the first days of Ramadan, followed by normalization by the twentieth day and a slight rise by the twenty-ninth day of Ramadan (6). The lowest serum glucose level in this study was 63 mg/dl. Others have shown a mild increase (7) or variation in serum glucose concentration (8,9), but all of them fell within physiological limits (6). From the foregoing studies, one may assume that the stores of glycogen, along with some degree of gluconeogenesis, maintain normal limits of serum glucose when a fast follows a large pre-dawn meal. However, slight changes in serum glucose may occur in individuals depending upon food habits and individual differences in metabolism and energy regulation.

Body weight during Ramadan fasting
(a) In normal subjects:
Weight losses of 1.7 kg. (10), 1.8 kg. (11), 2.0 kg. (12) and 3.8 kg (13) have been reported in normal weight individuals after they have fasted for the month of Ramadan. In one study that was over-represented by females, no change in body weight was seen (14). It has also been reported that overweight persons lose more weight than normal or underweight subjects(12). (b) In diabetics:
A review of literature shows controversy about weight changes in diabetics during Ramadan. (6,15-24). In one group of studies, patients had an increase in their weight (17,21). In another group, there were no change (15,19,22,23) or a decrease (6,16,18,20,24) in body weight. While no food or drink is consumed between dawn and sunset during the month of Ramadan, there is no restriction on the amount or type of food consumed at night (23,25). Furthermore, most diabetics reduce their daily activities (15,23) during this period in fear of hypoglycemia. These factors may result in not only a lack of weight loss, but also a weight gain in such patients (26). (See later discussion about nutrition and physical activity.)

Blood glucose variations during Ramadan fasting in diabetics

Most patients show no significant change in their glucose control (3,23,24,27). In some patients, serum glucose concentration may fall or rise (28-30). This variation may be due to the amount or type of food consumption, regularity of taking medications, engorging after the fast is broken, or decreased physical activities. In most cases, no episode of acute complications (hypoglycemic or hyperglycemic types) occurs in patients under medical management (9,15,16,22), And only a few cases of biochemical hypoglycemia without clinical hazards have been reported (17,19,25).

Other parameters of diabetes control during Ramadan fasting

In general, HbAIC values show no change or even improvement during Ramadan (15-18,20,22,23,25,27,28,32). Only two studies have reported slight increases in glycated hemoglobin levels(19,31). However, one report has emphasized the same increase in non-fasting patients as fasting patients (31), and the other has shown a return to initial levels immediately after the month of Ramadan (19).

The amount of fructosamine (17,22,24,30,32), insulin, C-peptide(23,30) also has been reported to have no significant change before and during Ramadan fasting.

Energy intake and serum lipid variables during Ramadan fasting in diabetics

The amount of Energy (calorie) intake have been reported in some of the literature, indicating a decrease in energy intake (24,28).

Most patients with non-insulin dependent diabtes mellitus (NIDDM, diabetes type II) and insulin dependent diabetes mellitus (IDDM, diabetes type I) show no change or a slight decrease in concentrations of total cholesterol and triglyceride (15-19,27,28,32). Increase in total cholesterol levels during Ramadan seldom occurs (23). As in healthy persons (33-36), few studies have reported increases in high-density-lipoprotein (HDL) cholesterol in diabetics during Ramadan (18,19,27). One report indicates an increase in low-density-lipoprotein (LDL) cholesterol and a decrease in HDL-cholesterol (28). Until there is a standardization of diabetes Ramadan research in three fundamental factors -- the Three D Triangle of drug regimens, diet control and daily activity -- the benefits or hazards of Ramadan fasting on diabetics serum lipids is unclear.

Other biological parameters during Ramadan fasting in diabetics

Serum creatinine, uric acid, blood urea nitrogen, protein, albumin, alanine amino-transferase, aspartate amino-transferase values do not show significant changes during the fasting period (15,17,32). Slight non-significant increases in some biological parameters may be due to dehydration and metabolic adaptation and have no clinical presentation.

FASTING GUIDELINES TO DIABETICS

During the last two decades, a better understanding of pathophysiological changes during Ramadan fasting in diabetic patients has provided a few guidelines on how to advise diabetics who want to fast. Physicians working with Muslim diabetics should employ certain criteria to advise their patients regarding the safety of Ramadan fasting.

The following criteria should be helpful in making such a decision (20,37):

Forbid fasting in:
All brittle type I diabetic patients;
Poorly controlled type I or type II diabetic patients;
Diabetic patients known to be incompliant in terms of following advice on diet drug regimens and daily activity;
Diabetic patients with serious complications such as unstable angina or uncontrolled hypertension;
Patients with a history of diabetic ketoacidosis;
Pregnant diabetic patients;
Diabetic patients will inter-current infections;
Elderly patients with any degree of alertness problems;
Two or more episodes of hypoglycemia and/or hyperglycemia during Ramadan.

Allow fasting in:
Patients who do not have the aforementioned criteria;
Patient who accept medical advisement.

Encourage fasting in:
All overweight NIDDM patients (except for pregnant or nursing mothers) whose diabetes is stable with weight levels 20% above the ideal weight or body mass index (body weight, kg/height, meters squared) greater than 28.

EDUCATION OF THE DIABETICS BEFORE RAMADAN

NIDDM patients and IDDM patients who insist on fasting should be given a few recommendations about fasting (16). They should be forbidden from skipping meals, taking medication irregularly or gorging after the fast is broken (26).

The principles of pre-Ramadan considerations are (37):
a. assessment of physical well being;
b. assessment of metabolic control;
c. adjustment of the diet protocol for Ramadan fasting;
d. adjustment of the drug regimen e.g. change long-acting hypoglycemic drugs to short-acting drugs to prevent hypoglycemia);
e. encouragement of continued proper physical activity;
f. recognition of warning symptoms of dehydration, hypoglycemia and other possible complications.

RECOMMENDATIONS DURING RAMADAN FASTING

I. Nutrition and Ramadan fasting:

Dietary indiscretion during the non-fasting period with excessive gorging, or compensatory eating, of carbohydrate and fatty foods contributes to the tendency towards hyperglycemia and weight gain (21,23). It has been emphasized that Ramadan fasting benefits appear only in patients who maintain their appropriate diets (24,38,39). Thus, in order to optimize control, diabetics must be reminded to abstain from the high-calorie and highly-refined foods prepared during this month (38).

II. Physical activity and Ramadan fasting:

Several studies indicate that light to moderate regular exercise during Ramadan fasting is harmless for NIDDM patients (15). It has been shown that fasting does not interfere with tolerance to exercise (40). It should be impressed upon diabetic patients that it is necessary to continue their usual physical activity especially during non-fasting periods (41)

III. Drug regimens for IDDM patients:

Some experienced physicians conclude Ramadan fasting is safe for IDDM patients with proper self-monitoring and close professional supervision (16). It is fundamental to adjust the insulin regimen for good IDDM control during Ramadan fasting. Two insulin therapy methods have been studied successfully:

Three-dose insulin regimen: two doses before meals (sunset and Dawn) of short-acting insulin and one dose in the late evening of intermediate-acting insulin (16).

Two-dose insulin regimen: Evening insulin combined with short-acting and medium-acting insulin equivalent to the previous morning dosage, and a pre-dawn insulin consisting only of a regular dosage of 0.1-0.2 unit/kg (25).

Home blood glucose monitoring should be performed just before the sunset meal and three hours afterwards. It should also be performed before the pre-dawn meal to adjust the insulin dose and prevent any hypoglycemia and post-prandial hyperglycemia following over-eating.

IV. Drug regimens for NIDDM patients:

Available reports indicate that there are no major problems encountered with NIDDM overweight patients who observe fasting in Ramadan (3). With proper changes in the dosage of hypoglycemic agents there will be low risk for hypoglycemia and hyperglycemia.

The authors of the largest series of patients treated with glibenclamide during Ramadan recommended that diabetics switch the morning dose (together with any mid-day dose) of this drug with the dosage taken at sunset (31).

V. Other health tips for reduction of complications:

1. Implementation of the 3D Triangle of Ramadan -- drug regimen adjustment, diet control and daily activity -- as the three pillars for more successful fasting during Ramadan.

2. Diabetic home management that consists of:
Monitoring home blood glucose especially for IDDM patients, as described above;
Checking urine for acetone (IDDM patients);
Measuring daily weights and informing physicians of weight reduction (dehydration, low food intake, polyuria) or weight increase (excessive calorie intake) above two kilograms;
Recording daily diet intake (prevention of excessive and very low energy consumption).

3. Education about warning symptoms of dehydration, hypoglycemia and hyperglycemia.

4. Education about breaking fast as soon as any complication or new harmful condition occurs.

5. Immediate medical help for diabetics who need medical help quickly, rather than waiting for medial assistance the next day.

6. Further attention on fasting during the summer season and geographical areas with long fasting hours.

VI. IDDM children and Ramadan fasting:

We do not encourage fasting for IDDM children. However, a few studies demonstrate that fasting is safe among diabetic adolescents. Of these studies, one study concludes that Ramadan fasting is feasible in older children and children who have had diabetes for a long time, and it concludes fasting does not alter short-term metabolic control. Nevertheless, fasting should only be encouraged in children with good glycemic control and regular blood glucose monitoring at home (25).

POST-RAMADAN SUPERVISION OF FASTING DIABETICS

After the month of Ramadan ends, the patients therapeutic regimen should be changed back to its previous schedule. Patients should also be required to get an overall education about the impact of fasting on their physiology (37).

THE RESEARCH METHODOLOGY ON DIABETICS DURING RAMADAN

From a methodological point of view, few research papers on Ramadan fasting are relevant because of the absence of control periods before Ramadan and afterwards, the absence of measurements during each week of Ramadan, a lack of attention to dietary habits, food composition, food value, caloric control, weight changes and the importance of the schedule during circadian periods.

It is recommended that all these factors should be taken into consideration and that all intervening and confounding variables should be under control. It is clear that more work should be done on Ramadan fasting to evaluate physiological and pathological changes with proper research methods (42).

Fasting during the entire month of Ramadan is reserved usually for healthy Muslims. However, many diabetic patients are allowed to fast periodically during Ramadan. The magnitude of periodic total fasting effect on blood glucose and hepatic glucagon depends on the number of fasting days (43), and this should be considered in all Ramadan fasting research activities.

CONCLUSION

The bulk of literature indicates that fasting in Ramadan is safe for the majority of diabetics patients with proper education and diabetic management. Most NIDDM patients can fast safely during Ramadan. Occasional IDDM patients who insist on fasting during Ramadan can also fast if they are carefully managed. Strict attention to diet control, daily activity and drug regimen adjustment is essential for successful Ramadan fasting.

To shed more light on pathophysiological changes in Ramadan fasting, in particular in Muslims diabetics, it is recommended that a multicentric international controlled clinical trial be employed to assess the effect of differences in gender, races, physical activities, food habits, sleep patterns and other important variables on physiologic and pathologic conditions during Ramadan fasting.