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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
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
Diabetic Ketoacidosis
Hyperosmolar Hyperglycemic state
Hyperosmolar Hyperglycemic state
Management of Diabetes related
complications during festival
Management of Diabetes related
complications during festival
Assessment of Diabetes patients before and
during festivals
Assessment of Diabetes patients before and
during festivalsPATIENT 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
Assessment of Diabetes patients before and
during festivals
• 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
Assessment of Diabetes patients before and
during festivals
• 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
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
