Introduction Culture and religion play an important part in the life of many people across the world...

Introduction

• Culture and religion play an important part in the life of many people across

the world

• In India, festivals hold a very important place

• Majority of Indian festivals are considered to be synonymous with eating,

feasting and gifting sweets

• Our festivals have a special sweet/ savoury item associated with them, e.g.,

– Ramadan (with its famed falooda)

– Diwali (mouth watering ladoos)

– Ganesh Chaturthi (the ubiquitous modak)

– Navratri (tender rasgullas)

– Christmas (famous Christmas cakes) and the New Year (alcohol and high

calorie food) are a few to mention

Introduction

• Festivals not only include feasting and relishing tasty food but also have

'fasting' as an integral part

• This fasting during festivals can last from days to months depending on

a person's religious faith

• Hindus fast during Vatapoornima, Karva Chauth, Janmashtami, Navratri,

Mahashivratri, etc

• Jains practice Paryushan, Muslims fast during the holy month of

Ramadan, Christians practice Lent, Buddhists also have Lent fasts

• Thus, most religious groups have fasting in their festival celebrations

Impact of festivals on Diabetes• Religio-cultural practices are an integral component of day-to-day

activities and impact an individual's health as well

• Health cannot be ignored whether it is a fasting or a feasting occasion

• Meeting a balance between 'health' and 'celebrations' is a tight rope

walk, especially for those with compromised health status

• Diabetics place an important challenge in this regard. Diabetes patients

are often confronted with a dilemma if they should 'fast' or 'feast‘

• The healthcare provider plays an important role in helping diabetes

patients sail through the festival season by enjoying themselves without

having an adverse impact on their health

Impact of festivals on Diabetes

• Fasts are characterised by a well-documented impact on metabolic

health in healthy individuals as well as in those with various metabolic

abnormalities

• In diabetics, their blood sugar levels can significantly vary during

festival days due to fasting, feasting or as a result of infrequent meals

• The medications, time of medications, insulin dosage, exercise

schedules, dietary recommendations are all impacted by festival time

Diabetic Complications During Festivals

• The major contributors towards inadequately managed diabetes during

festivals are:

– A sudden change in dietary habits

– Lack of monitoring

– Disrupted medication

• Some of the major potential diabetes-related complications of fasting and

feasting include dangerously low blood glucose (hypoglycaemia),

excessively high blood glucose (hyperglycaemia), Diabetic Ketoacidosis

(DKA), and Hyperosmolar Hyperglycaemic State (HHS)

• All of these complications are acute but serious complications in diabetes

patients that manifest suddenly and insidiously

Diabetic Complications During Festivals

• There is a significant increase in fasting and post-prandial plasma

glucose, total cholesterol, triglycerides and very low-density lipoprotein

(VLDL) cholesterol after Diwali

• Whereas, high-density lipoprotein (HDL) cholesterol is found to be

reduced significantly

• It is observed that festivals like Diwali are associated with significant

impairment in glycaemic control and lipid profile

• The other end of spectrum is fasting during Navratri by many devotees,

which commonly extends beyond 24 hours and often lasts for several

days, when even water is not allowed

• Such severe forms of extended fasting can lead to life-threatening

complications in already uncontrolled diabetics

Who Should Avoid Fasting During Festivals?

• Based on the observations during Ramadan, religious fasting in

general is discouraged in patients with type 1 diabetes by various

societies including the American Diabetes Association (ADA)

• Ritualistic fasting under peer and family pressure is often treated

as a test of personal religious faith, resulting in unrealistic strict

abstinence from all foods and drinks, including water

• This also includes stopping of all antidiabetic medications in

patients with diabetes

Who Should Avoid Fasting During Festivals?

Causes of Diabetes related complications during festivals

Category of patients at risk during festivals

Hypoglycaemia

• Frequent hypoglycaemia leads to inability of recognising

initial symptoms on subsequent episodes

• In individuals taking insulin and/or insulin secretagogues,

fasting and strenuous physical activity can cause

hypoglycaemia if medication dose or carbohydrate

consumption is not altered

Hypoglycaemia

Practical Points For Physicians To Communicate With Patients

• Physicians should advise the patients that fasting should not be

overdone, and fasting without adequate safeguards may predispose to

hypoglycaemia, especially when the patient is also receiving glucose

lowering medications

• Physicians should understand the patient's exact perspective of fasting,

including duration of fast, and stress on allowance for liquids and snacks

during the day, acceptance of sublingual foods and necessity to break

the fast in case of significant discomfort

• Physicians should explain the importance of modification in pre-fast diet,

hydration and medication change to the patient

What Should The Physician Advise/ Do In Patients Who Are Adamant To Fast

• Pre-fast meal assumes importance and should provide complex

carbohydrates with low glycaemic index and proteins like unprocessed

cereals, fruits, nuts and lentils

• Adequate water and fluids must be taken prior to the fast, especially in

cases where fluid intake will be restricted throughout the day

• Patients can perform routine daily activities easily, but elective

moderateto- highly vigorous exercise should be avoided

• Modification in antidiabetic pharmacotherapy to meet the patient's

requirements during the period of fasting is required

What Should The Physician Advise/ Do In Patients Who Are Adamant To Fast

Hyperglycemia

Diabetic Ketoacidosis

Hyperosmolar Hyperglycemic state

Management of Diabetes related complications during festival

Assessment of Diabetes patients before and during festivals


PATIENT ADVICES

• When the fast is broken at sunset with large meals often high in fats and

sugars, including fizzy drinks and fruit juices, it can lead to

hyperglycaemia

• Patients need to be advised how to choose healthier options, such as

diet drinks, which allow them to participate in the social occasion


• Patients require advice on timing and adjustment of insulin or oral

medication doses to prevent hypoglycaemia

• It is essential that patients with type 1 diabetes continue with

insulin, otherwise they may develop DKA, which can occur in the

absence of insulin even without food intake

• As patients do not take anything orally during the fasting hours, it

is important that they are advised to break their fast if they

become hypoglycaemic

• They should carry glucose and personal identification details with

them at all times

PATIENT ADVICES


• Many people often do not take tablets or inject insulin during

fasting hours, and some may not perform blood glucose tests

because of mistaken interpretation of religious instruction

• Poor attendance at clinics during some festivals is common, as

people tend to rest during the day

PATIENT ADVICES

Treatment related advise during festivals

Type 1 Diabetes

Treatment related advise during festivals

Type 2 Diabetes

Pregnancy and Festivals

• Fasting during pregnancy is believed to carry a high risk of death and disability to both

the foetus and the mother

• Some pregnant females with known diabetes (including gestational diabetes) insist on

fasting

• These women constitute a high risk group and their management requires intensive care

• The issues already discussed concerning the management of type 1 diabetes and type 2

diabetes also apply to pregnant women, along with more frequent monitoring and insulin

dose adjustment

• Pregnant women should be strongly advised not to fast

References

• Kalra S, Bajaj S, Gupta Y, Agarwal P, et al. Fasts, feasts and festivals in diabetes-1: Glycemic

management during Hindu fasts. Indian J EndocrinolMetab. 2015; 19(2): 198-203.

• Ibrahim MA. Managing diabetes during Ramadan. Diabetes Voice. 2007;52(2):19-22.

• Fatima J, Karoli R, Chandra A, et al. Ramadan fasting in patients with type 2 diabetes mellitus:

Experience from a teaching hospital. Indian Journal of Endocrinology and Metabolism.

2012;16(2):323-324.

• Pathan MF, Sahay RK, Zargar AH, et al. South Asian Consensus Guideline: Use of insulin in

diabetes during Ramadan. Indian Journal of Endocrinology and Metabolism. 2012; 16(4) :499-

502

• Hill J. Management of diabetes in South Asian communities in the UK. Nursing Standard.

2006;20(25):57-64.

• Levin ME, Pfeifer MA, editors. The uncomplicated guide to diabetes complications. 3"' ed.

American Diabetes Association 2009.

• American Diabetes Association Standards of Medical Care in Diabetes. Diabetes Care.

2015;38(1 ):S1-S93.

References

• Patel V, Morrissey J, Goenka N, et al. Diabetes care in the Hindu patient:cultural and

clinical aspects. Br J Diabetes Vasc Dis. 2001; 1: 132-5.

• Mathur N, Mathur R, Rawtani J. Impairment in glycemic control and lipid profile during

indian festival Diwali. Presentation Number: SAT-169, at The Endocrine Society's 94'h

Annual Meeting and Expo, June 23-26, 2012 - Houston, TX. Date of Presentation: June

23"', 2012.

• Dutta D, Biswas K, Sharma M, et al. Managing diabetes during Navratris with special focus

on Durga pujas. J Soc Health Diabetes. 2015;3(2):84-8.

• Jaleel MA, RazaSA, Fathima FN, et al. Ramadan and diabetes: As-Saum (The fasting).

Indian J EndocrinolMetab. 2011 ;15(4):268-273.

• IDF module 2011. Module 4. Available at: http://www.idf.org/diabetes-education-modules.

Last accessed: 23"' June 2015.

Thank You

Introduction Culture and religion play an important part in the life of many people across the world...

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