FASTING from dawn to dusk daily for a month is a tough challenge at the best of times.
But for someone with diabetes it is a potentially deadly endeavour.
Starving the body of food and water throughout the day, then bingeing on sweets and huge meals at night-time could easily bring on a fit which could ultimately send the sufferer
into a coma.
The possibility has thousands of Muslim diabetics facing a real dilemma during their traditional fasting month of Ramadan.
To make matters worse, Asians are four times more likely to develop diabetes than other ethnic groups, especially in later life - a time when many Asians turn increasingly to Islam.
The faith does allow them to abstain from the fast on health grounds as long as they donate money to help feed others instead.
But many are so devout that they decide to fast anyway, regardless of the risks.
They are barred from injecting themselves with insulin or monitoring blood sugar levels during the day as both activities are seen as breaking the fast - further increasing the risk of health problems.
The problem has led to a new study in Edinburgh highlighting widespread ignorance about the issues surrounding Ramadan and diabetes.
Now the study has won an award from the pharmaceutical industry, making funding available so its findings can be used to make Muslims across Scotland aware they could be putting their lives at risk.
Diabetes is caused by a shortage of insulin, the hormone produced by the pancreas which regulates blood sugar levels. The condition is a major cause of heart attacks, strokes, blindness and kidney failure.
Lesley Barrow, specialist diabetes nurse at Edinburgh’s Western General Hospital, is behind the research. "I started thinking about diabetes and Ramadan two years ago when a Muslim patient who was on insulin for his condition asked me how he could fast safely," she says.
"Diabetes is a serious concern for South Asian people, who are four times more likely to develop diabetes. They are more likely to suffer from the complications at an earlier age, like poor circulation which can lead to amputations. I decided to send out questionnaires to patients to find out what their needs were, and to health professionals, such as doctors, specialist diabetes nurses and dieticians, to find out what they knew about diabetes and Ramadan.
"All the patients who answered the questionnaire wished to fast safely and three quarters of them did fast. But only a third changed their diabetes treatment, leaving them at risk of hypoglycaemic [hypo, low blood sugar levels] and hyperglycaemic [hyper, high blood sugar levels] attacks.
"Both can result in the patient losing consciousness and slipping into a coma. One of the patients who responded to the questionnaire had been taken to hospital after suffering a very bad hypo."
She adds: "I was amazed to find that less than a third of health professionals who replied [to the survey] knew the date for Ramadan. They did advise changes in treatment for some patients, but problems like tiredness and overeating during Ramadan were subjects poorly addressed by health professionals.
"Drug regime adjustment, dietary control and daily activity advice is necessary for patients to fast safely. These needs are not being met by health professionals."
One of the key things which diabetic Muslims must do in order to fast safely is change their drug regime.
Barrow explains: "They need to change the timings of their medication, and the dosages. Most insulin and oral treatments need to be taken with or just after food. If patients take it at the wrong time they run the risk of a hypo or hyper attack."
Overeating at dusk, when the daily fast is over, is another common practice which is dangerous for diabetics.
"There is a tendency for people to overeat when they break their fast. They traditionally start with dates, and then have a big meal and lots of very sweet sweets," says Barrow. "The advice to people with diabetes is to try to eat the same size portions as they would normally eat when not fasting, and not to eat too many sweets and dates."
Finally, diabetics are more likely to suffer from tiredness than other people, so they should take more rest. "During Ramadan Muslims are very busy, praying maybe six or eight times a day, and a lot of Asians have very physical jobs in shops," says Barrow. "If they have diabetes they will need more rest."
As a result of the study - which involved 63 Asian diabetics and 40 health workers - the four diabetes clinics in the Lothians display information about Ramadan and diabetes for health professionals and patients.
Meanwhile, Barrow hopes to use the £1500 prize money awarded by the Association of British Pharmaceutical Industries Scottish Diabetes Industry Group to help fund linkworkers to visit Asians in the community.
SHE says: "I was absolutely gobsmacked to win the award. I’m really pleased that the award can now help in the community."
The initiative was welcomed by the leader of Lothians Muslims, who says diabetes causes serious problems for many during Ramadan, which this year ended on November 13.
Jalal Chaudry, who as the Edinburgh and East of Scotland representative on the Muslim Council of Britain represents the 9000 Muslims in the Lothians, says: "I have come across so many people suffering with diabetes and by the time it is time to break the fast they are in a miserable condition.
"Muslims don’t have to fast if they cannot do so on health grounds. They can give money to charities to pay for meals for other people. But a lot of people develop diabetes when they are over 60, which is also when many Asians are more inclined towards their religion, so many of them want to fast, they want to be purified, so they suffer."
Barrow’s research won the Diabetes Education Award at the ABPI Sharing Practice, Improving Care Awards, which were announced earlier this month.
The Scottish Diabetes Industry Group was set up by the ABPI to help improve life for the 120,000-plus people with diabetes in Scotland. John Hughes, chairman of the SDIG, says: "The Sharing Practice, Improving Care Awards are all about celebrating and rewarding the very best diabetes care in Scotland and this year’s winners are certainly fantastic examples of that."
Jim Eadie, director of ABPI Scotland, adds: "It is vital that diabetes is detected early and monitored carefully so as to avoid potentially life-threatening complications. The collaboration between the pharmaceutical industry and the NHS in applying quality care and effective healthcare solutions is crucial in tackling a condition affecting an increasing number of people in Scotland."
