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.
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.