Primary Care Providers’ Knowledge and Practices of Diabetes Management During Ramadan

Abstract

There are an estimated 3.5 million Muslims in North America. During the holy month of Ramadan, healthy adult Muslims are to fast from predawn to after sunset. While there are exemptions for older and sick adults, many adults with diabetes fast during Ramadan. However, there are risks associated with fasting and specific management considerations for patients with diabetes. We evaluated provider practices and knowledge regarding the management of patients with diabetes who fast during Ramadan. A 15-question quality improvement survey based on a literature review and the American Diabetes Association guidelines was developed and offered to providers at the outpatient primary care and geriatric clinics at an inner-city hospital in New York City. Forty-five providers completed the survey. Most respondents did not ask their Muslim patients with diabetes if they were fasting during the previous Ramadan. Knowledge of fasting practices during Ramadan was variable, and most felt uncomfortable managing patients with diabetes during Ramadan. There is room for improvement in educating providers about specific cultural and medical issues regarding fasting for patients with diabetes during Ramadan.

Introduction

Islam is one of the fastest growing religions in North America, with an estimated population of nearly 3.5 million in 2010 with a projected population of 10.3 million in 2050. ¹ Fasting from dawn to dusk during the month of Ramadan is 1 of the 5 pillars of Islam. While the Koran exempts specific people from fasting, such as those who are ill, many Muslims with diabetes are dedicated to fasting during Ramadan. ² The Epidemiology of Diabetes and Ramadan (EPIDIAR) study, a large epidemiological study of 12 243 Muslims with diabetes in 13 different Muslim countries, revealed that 79% of Muslims with type 2 diabetes fasted for more than 2 weeks during the month of Ramadan. ³ However the practice of fasting during Ramadan for adults with diabetes is known to carry significant risks and complicate the management of diabetes. The EPIDIAR study showed a significant increase in severe hypoglycemic episodes during Ramadan compared with other months. ³ Other complications of fasting for patients with diabetes during Ramadan include hyperglycemia, dehydration, ³ volatility of blood sugar levels, especially for patients on insulin and sulfonylurea medications, ⁴ fluctuations in lipids, renal function, ⁵ and body composition.^5,6

However, there is a lack of studies in the United States regarding the knowledge and management of diabetes during Ramadan by both patients and providers. EPIDIAR showed that less than half of the study population made changes in diabetes treatment doses during Ramadan, and 62% of patients with type 2 diabetes were provided with fasting guidelines by their provider. ³ Previous studies from Europe indicated low levels of both provider and patient knowledge of specific issues, management, and complications for patients with diabetes who fast during Ramadan.^7,8 Therefore, many providers are not aware of the specific issues regarding diabetes care during Ramadan; nor do they properly counsel or educate their patients with diabetes who fast. This further emphasizes the need for culturally appropriate health education for different ethnic groups, ⁹ who may fast for religious purposes.

Given the absence of studies specifically in the United States, the purpose of this pilot study was to better understand provider practices and knowledge of diabetes care during Ramadan for Muslim patients in an inner-city primary care clinic in New York City to identify areas to educate and improve provider awareness.

Methods

Survey Procedures and Setting

A 15-question online survey was developed to evaluate diabetes management, knowledge, and provider practices for the preceding Ramadan of 2014 (June 28 to July 28) as part of a pilot for a quality improvement project to improve diabetes care within the primary care clinics. The survey was administered through email to all providers who see primary care patients (attending physicians, geriatric medicine fellows, medical residents) at the adult outpatient primary care and geriatric medicine clinics at Bellevue Hospital in New York City, which services a culturally diverse inner-city population. The project was reviewed and exempted for full institutional review board review by the New York University Institutional Review Board. The survey was open to respondents for the month of October 2014 and sent twice. All survey responses were anonymous and confidential. The final response rate was 41.3% (45 of 109 providers).

Questionnaire Content

The survey was based on the literature regarding common practices during Ramadan and the American Diabetes Association consensus statements on the management of diabetes during Ramadan.^2,10,11 The first part of the survey asked about provider practices of managing diabetes for Muslim patients during the most recent Ramadan in 2014. This included asking patients with diabetes if they fast during Ramadan, made adjustments to oral hypoglycemic agents or insulin, made recommendations for blood sugar monitoring, nutrition, and lifestyle recommendations, outlined indications to break their fast, and discussed the possible medical risks of fasting. Next participants were asked if they had difficulty controlling blood sugar during Ramadan for patients who were fasting, and a 5-point Likert-type scale question of their current comfort level for managing patients with diabetes who fast. The final 5 questions assessed respondent’s general knowledge regarding the principles and practices of fasting during Ramadan.

Analysis

We performed cross-sectional analysis of the responses as an entire group of providers as well as by attending physicians and physicians in training (medical residents and geriatric fellows). Attending physician responses comparisons were made to trainee physician responses by bivariate analysis using chi-square test.

Results

Provider Characteristics

Twenty-two (49.9%) of the respondents were attending physicians and general medicine faculty, 3 (6.7%) were geriatric medicine fellows, and 20 (44.4%) were medicine residents at New York University Department of Medicine.

Knowledge Regarding Fasting During Ramadan

Table 1 shows primary care provider’s knowledge of the principles, common practices, and possible risks of fasting for patients with diabetes during Ramadan. While nearly all respondents accurately identified possible complications of fasting for adults with diabetes, the responses to the other questions found a mix of provider knowledge specific to Ramadan.

Table 1.

Provider Knowledge of Principles and Common Practices During Ramadan.

Practice Questioned	Correct Response	Provider Response a
		True		False
Abstinence from oral medication use from predawn to after sunset	True	37.78 (n = 17)		62.22 (n = 28)
Restrict food or fluid intake between sunset and dawn	True	42.22 (n = 19)		57.78 (n = 26)
Must fast regardless of chronic conditions	False	13.33 (n = 6)		86.67% (n = 39)
		0	1	2	3	4	5
Usual number of meals eaten per day	2	2.22 (n = 1)	33.33 (n = 15)	62.22 (n = 28)	2.22 (n = 1)	0	0
		Hypoglycemia	Hyperglycemia	Diabetic Ketoacidosis	Dehydration/ Thrombosis	All of the Above
Possible complications of Fasting	All of the above	6.67 (n = 3)	0	0	0	93.33 (n = 42)

a

Provider responses reported as percentage (%) of respondents out of total surveyed (n = 45).

Provider Practices During Ramadan

Table 2 shows the results of provider’s practices for diabetes management during Ramadan 2014. Of the providers only 15 (34.1%) asked their Muslim patients with diabetes if they were fasting. When applicable, most providers did not adjust oral hypoglycemic agents (42.2%) or insulin doses (37.8%). Few providers made any recommendations regarding blood sugar monitoring (11.1%), food/diet, and exercise recommendations (25%), discussed medical risks of fasting (22.7%), or discussed specific circumstances of when to break their fast for medical reasons (6.7%). The majority of providers experienced difficulty with controlling blood sugar for patients with diabetes who fasted during Ramadan (52.3%).

Table 2.

Provider Practices in Caring for Patients Who Fast During Ramadan.

Survey Question	Clinical Recommendation	Provider Response (%)
		Yes	No	Not Applicable
Asked Muslim patients with diabetes if they were fasting	Yes	34.09	38.64	27.27
For Muslim patients with diabetes who were fasting, did you
Adjust oral hypoglycemic agents	Yes	26.67	42.22	31.11
Adjust insulin use	Yes	24.44	37.78	37.78
Make blood sugar monitoring recommendations	Yes	11.11	53.33	35.56
Experience difficulty controlling blood sugar	No	13.64	52.27	34.09
Make food and diet recommendations	Yes	25.00	43.18	31.82
Discuss medical risks of fasting with patient	Yes	22.73	43.18	34.09
Discuss specific circumstances when a patient should break their fast	Yes	6.67	60.00	33.33

Finally of the 45 providers surveyed, when asked about current comfort level managing patients with diabetes who are fasting: 5 (11.1%) felt very uncomfortable, 23 (51.1%) felt somewhat uncomfortable, 6 (13.3%) were unsure, 10 (22.2%) felt somewhat comfortable, and only 1 (2.2%) felt very comfortable.

Comparison Between Attendings and Trainees

Attending physicians were more likely than providers in training (medical residents or geriatric medicine fellows) to ask patients if they were fasting for Ramadan (80% vs 20%; P = 0.037). However, there were no other statistically significant differences or trends toward significance between attending physicians and trainees in management of diabetes or in knowledge of Ramadan practices.

Discussion

Although the risks of fasting for patients with diabetes are well documented, providers in the United States who care for a multiethnic population may not fully be aware issues of fasting by Muslim patients with diabetes during Ramadan. A key challenge is educating providers who may not be familiar with the principles and common practices of their patients who observe Ramadan. Also it is important to increase awareness for both health providers and patients of the possible risks of fasting during Ramadan and the recommended guidelines for managing diabetes. While there is an absence of studies conducted in the United States, prospective studies from other countries using educational programs for patients with diabetes who fast during Ramadan suggest such interventions may prevent serious complications such as severe hypoglycemia.^12,13 Other studies have shown improved overall glycemic control among patients with diabetes who fast during Ramadan who actively have their diabetes medications adjusted.^14,15

This study shows that for a large inner-city primary care clinic in the United States that serves a multiethnic population, there are areas for improvement to increase awareness, education, and provider comfort in caring for Muslim patients with diabetes who fast during Ramadan. Many of our health care providers had variable knowledge regarding Ramadan, did not follow American Diabetes Association guidelines, and most felt uncomfortable in their management of diabetes during Ramadan. However, there were limitations to our study. We had a low response rate, which could give nonresponse bias; however, the response rate is in line with other physician surveys. ¹⁶ Also our sample size is comparatively small, and because the survey was administered 2 months after the preceding Ramadan, the self-reported provider practices during this time may have recall and social desirability biases.

Managing chronic diseases in a diverse population necessitates culturally appropriate education and care, ⁹ which highlights diabetes among Muslims during Ramadan as well as fasting practices in other religions. ¹⁷ Fortunately, given the wealth of information and studies from other countries, there is a foundation to create quality improvement projects focused on education, knowledge, and awareness of both health providers and patients regarding diabetes management during Ramadan in the United States. Future studies should attempt to understand the role of culture, behavior, and the environment for developing such interventions in the United States, and how that may be different from other countries. Furthermore, identification of specific subpopulations who are at particularly high risk for the complications of fasting should be done, for example older adults and adults with multiple chronic conditions who may be at high risk for hypoglycemia.^18,19

Conclusion

Our pilot study showed that most providers in an inner city primary care clinic did not follow recommendations and felt uncomfortable managing diabetes during Ramadan. There is an opportunity to develop interventions to improve the quality of care for patients with diabetes who fast during Ramadan.