Physician Awareness in Diabetes Management During Ramadan 2015—A Focus Group Discussion

US Endocrinology, 2017;13(1):30–4 DOI: https://doi.org/10.17925/USE.2017.13.01.30

Abstract:

Background: Diabetic Muslims who wish to fast are recommended to undergo medical counseling prior to fasting to prevent complications. This study assesses knowledge, attitudes, and practices, and identifies issues related to building capacity for physicians treating diabetic patients. Methods: We conducted a qualitative study based on focus group discussions with primary healthcare center (PHCC) doctors who manage diabetic patients in the Riyadh region. Results: There is a lack of knowledge of the classification system for risk assessment of diabetic patients who fast during Ramadan. All the responses showed that there were misconceptions regarding nitroglycerin tablets placed under the tongue to nullify fasting. Other issues addressed by respondents include the following: how to adjust the dose and subsequently convince the patient to follow a new regimen, loss of patient follow-up due to referral to the hospital, the refusal of some laboratories to perform examinations for patients referred from other PHCCs, and lack of patient medication compliance. Conclusion: The study reported a lack of knowledge among respondents regarding therapeutic and lifestyle management of diabetic patients during Ramadan. Other issues addressed by participants include lack of healthcare services at primary healthcare center facilities and services not working effectively. To empower physicians and improve knowledge, attitude, and practices for managing diabetic patients during Ramadan, experience, continuous training, as well as fully equipped healthcare centers (including both laboratory and pharmaceutical medical supplies) play a crucial role.
Keywords: Diabetes, Ramadan, management, physician, focus group, primary healthcare center, type 2 diabetes, fasting
Disclosure: Fatima Younis Al Slail, Haroon UR Rashid, Sahar Mohamed Fadl, and Omer Osman Kheir have nothing to declare in relation to this article. This work was funded by the National Diabetes Prevention and Control Program, Ministry of Health, Saudi Arabia. There were no publication fees associated with the publication of this article.
Compliance with Ethics: All procedures were followed in accordance with the responsible committee on human experimentation and with the Helsinki Declaration of 1975 and subsequent revisions.
Authorship: All named authors meet the International Committee of Medical Journal Editors (ICMJE) criteria for authorship of this manuscript, take responsibility for the integrity of the work as a whole, and have given final approval to the version to be published.
Received: January 04, 2017 Accepted March 14, 2017
Correspondence: Fatima Younis Al Slail, National Diabetes Prevention and Control Program, Ministry of Health, Prince Abdul Aziz Bin Mosaed Bin Jalawi Street, Riyadh, Saudi Arabia. E: fatima.alslail@gmail.com
Open Access: This article is published under the Creative Commons Attribution Noncommercial License, which permits any noncommercial use, distribution, adaptation, and reproduction provided the original author(s) and source are given appropriate credit.

Muslims represent 18–25% of the global population, which is approximately 1.1–1.5 billion people.1 There are about 50 million Muslims worldwide with diabetes who fast during the holy month of Ramadan each year.2 All healthy Muslims aged from late childhood or early adolescence or puberty (which ranges from 10–14 years and over) are commanded to fast from sunrise to sunset during the consecrated month of Ramadan. They must refrain from all oral intake of food, water, beverages, and medications during the fast and must also avoid sexual contact.3 Certain groups are exempted from fasting temporarily or permanently; the sick, the elderly, travelers, pregnant women, and breastfeeding women.4

Due to the nature of fasting, diabetic patients who fast have an increased risk of serious events, and these risks may rise in Ramadan due to the longer fasting periods. Fasting may lead to complications such as hypoglycemia, hyperglycemia with or without ketoacidosis, thrombosis, and dehydration.5 Thus, several guidelines have been formulated.6 However, there are gaps regarding diabetes management in Ramadan.

There is a detailed classification system for risk assessment of diabetic patients who fast during Ramadan, and the classification varies according to risk severity.7 There are several widely accepted compatibility standards for advice against fasting. Physicians should be aware of these situations when addressing and advising patients. However, asking the patient not to fast based on scientific evidence could not only lead to the patient fasting without telling their doctor but also may offend the cultural and religious values of the patient.3 Religious leaders, as well as healthcare professionals, should provide education and support for safer fasting during Ramadan.2

The American Diabetes Association recommends the use of patient-centered care (PCC) in the management of all diabetes cases.8 PCC is an approach that is sensitive towards the patient’s preferences, needs, and values.9 Furthermore, Ramadan-focused education for diabetic patients has been proved to be essential in empowering them to change their lifestyles during Ramadan.10

Patients can face difficulties in maintaining their pre-Ramadan medication schedules, as they fear breaking their fast if they take them during the fasting period. This may result in some patients taking their medication too early, too late, or stopping them completely. Alternative routes of drug administration should be considered, as certain routes do not nullify fasting. Muslim scholars, medical practitioners, pharmacists, and specialists in other human sciences agree without opposition that topical routes, such as eye drops, ear drops, and sublingual tablets, such as nitroglycerin tablets (used for the treatment of angina), do not nullify fasting. In addition, subcutaneous (SC), intramuscular (IM), and intravenous (IV) medications do not affect fasting, unless it is intentionally administered for nourishment.11–13

Counseling before Ramadan is essential to all diabetic patients who are willing to fast during Ramadan, in order to adjust their medication timing, medication doses, and to optimize dietary changes and patterns of physical activity. Self-monitoring of blood glucose levels is especially important to detect acute symptoms. Most diabetic patients do not undertake pre- Ramadan counseling, as some believe it is non-mandatory. Effort is required to convince diabetic patients who are aiming to fast to attend pre-Ramadan counseling visits.7,14–15

Thus, physicians should work for their patients to prepare a suitable and individualized diet and medication plan.3 All diabetic patients wishing to fast during Ramadan should receive detailed health advice 1–2 months before the start of Ramadan. The aim of this study is to assess the knowledge, attitude, and practices of physicians as well as identify issues related to diabetic patients wishing to fast during Ramadan.

Methods
Health services in Saudi Arabia are provided through different partners including public hospitals and primary healthcare centers (PHCCs), government health sectors, such as the Ministry of Health (MOH), Military Health Services and University Health Institutions, which are structured to deliver free healthcare services to Saudi citizens. In addition to this, private sector health services, through its clinics and hospitals, constitute 31.1% of the total healthcare services in KSA in 2013.

A study protocol was submitted to the ethics committee of the Ministry of Health for approval; ensuring adherence to ethical principles such as those specified by the World Medical Association Declaration of Helsinki, and ethical approval was granted.

This study was qualitative in design and was conducted using two focus group discussions in primary healthcare (Etiga PHC). Each group included 12 participants who were physicians working in PHCCs. The two groups were categorized by gender; 12 males and 12 females were selected from 12 PHCCs by choosing one male and one female from each center. The physician age range was 30–57 years, and their clinical experience varied from 6–28 years.

The inclusion criteria were:
• Physicians working in PHCCs for more than five years.
• Physicians who independently manage more than 30 diabetic patients in a week.
• Two physicians should be selected from each PHCC.

The focus group discussion was conducted during Ramadan 1436H (June 2015). We developed a topic guide to discuss the health-seeking behavior of diabetic patients, that is, knowledge, attitude, physician practices, and capacity. The discussions were all conducted in English.

The participants who met the eligibility criteria and agreed to take part were enrolled. Each focus group session was attended by three investigators; one acted as the facilitator and two as note-takers. Participants were presented with a brief introduction describing the focus group process, the goals and objectives of the study, and explaining that sessions would be taped but participants would remain anonymous.

References:
1. An Analysis of the World Muslim Population by Country/Region, 2005. Available at: www.factbook.net/muslim_pop.php (accessed April 14, 2005).
2. Bravis V, Hui E, Salih S, et al., Ramadan Education and Awareness in Diabetes (READ) programme for Muslims with Type 2 diabetes who fast during Ramadan, Diabet Med, 2010;27:327–31.
3. Niazi AK, Kalra S, Patient centred care in diabetology: An Islamic perspective from South Asia, J Diabetes Metab Disord, 2012;11:30.
4. The Holy Quran, Sura 2: Verses 183–185.
5. Salti I, Benard E, Detournay B, et al., A population-based study of diabetes and its characteristics during the fasting month of Ramadan in 13 countries: Results of the epidemiology of diabetes and Ramadan (EPIDIAR) study, Diabetes Care, 2004;27:2306–11.
6. Al-Arouj M, Bouguerra R, Buse J, et al., Recommendations for management of diabetes during Ramadan, Diabetes Care, 2005;28:2305–11.
7. Beshyah S, Benbarka M, Sherif I, Practical management of diabetes during Ramadan fast, Libyan J Med, 2007;2:185–9.
8. Inzucchi SE, Bergenstal RM, Buse JB, et al., Management of hyperglycemia in type 2 diabetes: a patient centered approach, Diabetes Care, 2012;35:1364–79.
9. Committee on Quality of Health Care in America: Institute of Medicine, Crossing the Quality chasm: A New Health System for the 21st Century, Washington, DC: The National Academies Press; 2001.
10. Fatim J, Karoli R, Chandra A, Naqvi N, Attitudinal determinants of fasting in type 2 diabetes mellitus patients during Ramadan, J Assoc Physicians India, 2011;59:630–4.
11. Ramadan Health and Spirituality Guide, 2006. Available at: http:// ebookee.org/Ramadan-Health-and-Spirituality-Guide_132743.html (accessed April 2, 2013).
12. Ali R, Siddiqui H, Anjum Q, et al., Knowledge and perception of patients regarding medicine intake during Ramadan, JCPSP, 2007;17:112–3.
13. Aadil N, Houti IE, Moussamih S, Drug intake during Ramadan, BMJ, 2004;329:778–82.
14. Qureshi B, Diabetes in Ramadan, J R Soc Med, 2002;95:489–90.
15. Fox ER, Birt A, James KB, et al., ASHP guidelines on managing drug product shortages in hospitals and health systems, Am J Health Sys Pharm, 2009;66:1399–406.
16. Colliers International, Kingdom of Saudi Arabia Healthcare Overview, 2012. Available at: www.colliers.com// media/961B1B350CF146FE910AFDBECDCC605A.ashx (accessed May 25, 2015).
17. Al-Arouj M, Assaad-Khalil S, Buse J et al., Recommendations for management of diabetes during Ramadan, Diabetes Care, 2010;33:1895–902.
18. Zarkin GA, Dean N, Mauskopf JA, Williams R, Potential health benefits of nutrition label changes, Am J Public Health, 1993;83:717–24.
19. Center for Science in the Public Interest: Menu labeling. Available at: www.cspinet.org/menulabeling/ (accessed July 22, 2009).
Keywords: Diabetes, Ramadan, management, physician, focus group, primary healthcare center, type 2 diabetes, fasting