SABeshyahMedicineandFiqhUnitedatLast1:9 58

SPECIALCOMMUNICATION

Fasting During The month of Ramadan For People With Diabetes:

CenterforDiabetesandEndocrinology,SheikhKhalifaMedicalCity,AbuDhabi,UnitedArabEmirates

*Correspondingauthor:SABeshyahEmail:Beshyah@yahoo.com
Published:06September2009
IbnosinaJournalofMedicineandBiomedicalSciences2009,1(2):58-60
Received:31August2009
Accepted:06September2009
Thisarticleisavailablefrom:http://www.ijmbs.org
ThisisanOpenAccessarticledistributedunderthetermsoftheCreativeCommonsAttribution3.0License
whichpermitsunrestricteduse,distribution,andreproductioninanymedium,providedtheoriginalworkisproperlycited.

Abstract Fasting during the lunar month of Ramadan is a given with no complacency with the potential health risks
religious obligationforalladultMoslems. butwithgreatsensitivitytothepatientsreligiousfeelings.
Undercertaincircumstances,
afewgroupsareexemptfromfastingsuchasbeing“sick” as Introduction
judged by an experienced doctor. Recent collaboration Daytime fasting for 29-30 days during the lunar month of
between the International Islamic Fiqh Academy and The Ramadan is compulsory for adult Muslims. Being one of
Islamic Organization for Medical Sciences produced a thefivepillarsofIslammakeitaverysacredduty.Thereare
comprehensive guidance based on extensive review of the severalgroupswhoareexemptfromfasting.Being“sick” is one
evidence of possible risk to diabetic patients if they of these exemptions (1). However, for many years
observefasting.Thenewguidancecategorizedpeoplewith medicalandFiqhexpertshavebeentalkingseparatelyabout
diabetesinto4groupsaccordingtotheirrisk.Group1and themedicalissuesthatmayjustifytakingadvantageofthe
2areexemptedfromfastingastheyhaveriskfromfasting. exemptionallowedforbeing“sick”.Preachersdependonthe
Theseincludedpatientswithpoorglycemiccontrolorwith specific personal advice of an “expert Moslem physician” to
complicationsandseriouscoexistingillnessesinadditionto decide conditions in which fasting may “make disease worse
type1patientsandpregnantwomenwithdiabetes.Patients in or delay healing” as the guiding principles whereas
groups 3 and 4 are those with moderate to low risk of doctorswereusingthemedicaljargonsuchasindicatedand
harmfromfasting.Theseareexemplifiedbyuncomplicated contraindicatedwithvariableopinions.Thoughmostofthe
patientswithstablecontrolonoraldrugsnotassociatedwith researchwasonhealthyvolunteers,diabeteswassingledout
excessriskofhypoglycemia.Thesegroupsofpatientshave no withthelions’shareofinterestfrommedicalresearchers(2,
harm but may even benefit from fasting. Doctrs and religious 3). The recent decree issued at the meeting of the Council of
scholars have a joint responsibility to properly assess and theInternationalIslamicFiqhAcademyoftheOrganization of
advise patients to choose to fast or not to fast in line with Islamic Conference at its nineteenth session held in the
these recommendations. The advice should be

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IbnosinaJournalofMedicineandBiomedicalSciences2009 59

EmirateofSharjah,UAEbetween26thand30thApril2009 bloodglucoselevelsof180-300mg/dL(10.0-16.5mmol/l) or
canjustifiablybecountedasalandmarkevent.Itresulted from high blood glycosylated Haemoglobin (A1c greater
the cooperation between the Islamic Organization for than10%),renalimpairment,macrovasculardisease,those who
Medical Sciences (based in Kuwait) and the International live alone and are treated with insulin injections or oral
IslamicFiqhAcademyonthebasisoftheagreementsigned insulin secretagogues. In addition, patients who suffer from
between the two bodies. Previously, the Academy has conditions that add additional risks to them, elderly people
commissionedtheOrganizationtoconductastudytomake with other diseases and patients who are receiving
recommendations on the issue of “diabetes and fasting of treatments that interfere with their cognitive function were
Ramadan”. The decree was based on the proceedings of two countedinthisgroup.
symposia held by the Organization in November 2007 and
April 2008 and additional deliberation in the latest Category III
Academy’ssession(4).Itwillhelpsetthebasisforinformed These patients have a medium risk of complications as a
individualdecisiontobemadebythepatientssupportedby resultoffastingsuchasdiabeticpatientswithstablesituations
thephysiciansandscholars. andcontrolledbytheappropriateoralhypoglycaemicagents
(insulinsecretagogues,suchassulphonylureas).
Medical Basis for Fiqh Rulings on Fasting in Diabetes
Category IV
The FiqhAcademy’s decree started by defining the 4 main Patients with low risk of complications as a result of
typesofdiabetes(type1,type2,othertypesanddiabetesof fasting,includingdiabeticpatientswithstablesituationsand
pregnancy)inlinewiththeAmericanDiabetesAssociation and controlled by diet and non-insulin secretagogues (such as
World Health organization criteria for diagnosis and Metformin and Glitazones).
classification of diabetes (5). When considering who can fast,
diabetic patients were classified into four categories
medicallyinlinewiththeexpertrecommendationspublished in To Fast or Not to Fast?
2005 (6). The ruling about feasibility to fast or not to fast is ThefiqhrulesofcategoriesIandIIaredifferentfromthose
given below for each category separately. The four forcategoriesIIIandIV. Rulingincasesofthecategories I and II
categoriesareasfollows: is based on the certainty or the predominance of probability
that harm will occur to the patient if he or she fasts based on
Category I the assessment of the expert trustworthy
This included patients with very high risk of serious doctor.Therefore,thepatientswithcasescontainedtherein are
complications from fasting in patients suffering from permitted to break the fast and are indeed prohibited
certainmedicalconditionscharacterizedbyonepathological fromfastingtowardoffharmingthemselvesinaccordance
situation or more of the following groups: severe withtheteachingsoftheHolyQuran“and let not your own
hypoglycemiaduringthethreemonthsprecedingthemonth hands throw you into destruction (Sura 2: verse 195) and “
ofRamadan,patientswhofrequentlyhavehypoglycemiaor and do not destroy one another: for, behold, God is indeed
hyperglycemia, patients with hypoglycemia-unawareness. a dispenser of grace unto you(Sura4:Verse29).Thephysician
Patients known to have difficulty in controlling diabetes for shouldexplaintothemtheseriousnessofharmfromfasting on
long periods, diabetic ketoacidosis or hypoglycemic them, and the enormous potential (high likelihood) for
comaduringthethreemonthsprecedingRamadan. complications which are dangerous to their health or their
Patients with other acute illnesses associated with diabetes, lives. The doctor must exhaust the appropriate medical
those with diabetes who have obligation to undertake hard procedures that enable the patient to fast without harming
types of physical labor, patients with diabetes who are on themselves.TheprovisionsoffastinginRamadantoexcuse those
renal who have diabetes in the categories I and II above
dialysis,womenwithdiabetesduringpregnancyandalltype pursuanttotheHolyQuran’steachingsaying:“But whoever of
Idiabetespatientswereincludedinthisgroup. you is ill, or on a journey, [shall fast instead for the same]
number of other days; and [in such cases] it is incumbent
Category II upon those who can afford it to make sacrifice by feeding
This includes patients with high risk of complications as a needy person” (Sura 2: Verse: 184). The academy has
aresultoffasting,asthoughtbytheirdoctors,suchasthe indeedstatedthattofastwithknownriskofharmbyfasting
following: poor glycaemic control such as running high

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SABeshyahMedicineandFiqhUnitedatLast1:9 60
isa“sin”despitetheintegrityoftheprocessoffastitself. Final Remarks In conclusion, the proper clinical
management of diabetes during Ramadan fast is a prime
However, the rule of categories III and IV is completely example for culturally-
different. It is not permissible for patients in these 2 sensitivediabetescare.Itneedsablendofthefundamental
categoriestobreakthefast.Themedicalliteraturedoesnot principlesofgoodmedicalpracticewiththespecificcultural
indicate any possibility of harmful complications to their andethnicneedsofcommunitiesandindividuals.Effortsof
health and their lives and many of them may benefit from themultidisciplinarydiabetescareteamandoutsideagencies
fasting.Doctorsareboundbytheseprovisionstoestablish needtobetimelymobilizedandmasterlyorchestratedonan
theappropriatecategorizationofeachcaseindividually. annualbasistoguidepatientsthroughthefastingandfeasting
seasonsafely.Therecentdecreebythefiqhacademyhelped
Responsibilities of Health Care Professions, Scholars clarifythegeneralprinciplesinalanguagethatbothdoctors
and Organizations andscholarscanunderstandandthereforetheycansensibly
Finally,theAcademyrecommendsthefollowing: (1)Doctors engageindiscussionsaboutindividualcases.
are required to the briefed with an acceptable knowledge of
figh provisions on this subject, and this requires the References
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circulated to those concerned (7). (2)Scholars and preachers 2. SulimaniR.A.,FamuyiwaF.O.,LaajamM.A.Diabetes
are required to instruct patients mellitus and Ramadan fasting: the need for a critical
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These will significantly reduce its negative effects and Hassanein M., Ibrahim M.A. et al. Recommendations
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(4) The Islamic Organization for Medical Sciences in

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