Cultural considerations in diabetes: controlling HbA1c in a patient observing Ramadan
Consider the timing of diabetes patients for patients who are fasting for Ramadan.
The patient has had type 2 diabetes for at least 15 years.
He typically sees a primary care provider in the United Arab Emirates.
Approximately 3 months prior to this visit, he came to a different medical facility in the United States for evaluation for liver transplantation and was subsequently hospitalized. At the time of hospital discharge, his diabetes medication regimen was adjusted, and it was recommended that he come to this medical institution for ongoing evaluation and consideration for liver transplantation.
He is currently taking half a tablet of sitagliptin 50 mg (total 25 mg) by mouth once daily in the morning. His glycated hemoglobin (HbA1c) is 7.4% at the current visit. He reports 100% compliance with this medication. At this time, his hemoglobin is noted to be 8.3 g/dL; given his anemia, there are concerns about the accuracy of his HbA1c measurement.
History of diabetes therapy
At the time of his initial diagnosis of diabetes, he was prescribed oral medications. Approximately 2 years ago, he was advised to take insulin. He acknowledges that he was nonadherent with insulin administration. The patient does not recall the type of insulin he was prescribed. He reports that when he traveled to the United States for evaluation for liver transplantation and was subsequently hospitalized, he was advised to stop insulin therapy at the time of discharge and resume taking sitagliptin 25 mg by mouth once daily.
The patient reports no change in appetite and currently eats 2 meals per day. He reports that he is observing Ramadan, which started this morning. As of today's visit, he reports that he has been fasting all day and plans to eat 2 meals after sunset each day during Ramadan. His meals typically consist of rice, meats, and approximately 2 to 3 dates per day as snacks.
The patient states that he walks for 30 minutes most days of the week.
The patient has not been monitoring blood glucose at home recently and reports that his meter is broken.
The patient reports no known family history of diabetes.
Review of systems
Eyes: Results of an eye examination performed 1 year ago raised a suspicion of retinopathy. He has a follow-up eye examination scheduled in 1 month.
Cardiac: He is taking aspirin, carvedilol, and pravastatin. He has recently been evaluated by a cardiologist and has a known history of severe triple-vessel coronary artery disease for which he is currently advised to seek monthly follow-up. His ejection fraction as measured in the past month was 64%, and there was concern about congestive heart failure when he initially arrived in the United States. A cholesterol panel performed in the past month revealed a low-density lipoprotein level of 69 mg/dL. His blood pressure at today's visit is 111/67 mm Hg.
Neurologic: He reports upper and lower extremity numbness and tingling.
Sleep: He denies a history of sleep apnea.
Renal: He is receives dialysis on Mondays, Wednesdays, and Fridays. His creatinine level is 3.8 mg/dL with a creatinine clearance of 20 mL/min. He has monthly nephrology follow-up visits.
Weight: He denies recent weight loss or gain. His body mass index is 19.7 kg/m2 and his current weight is 55.6 kg.
Gastrointestinal: The patient was diagnosed with hepatitis B virus infection approximately 5 years ago, which is now associated with cirrhosis and complications of ascites, varices, and an episode of hepatic encephalopathy. He has monthly gastroenterology follow-up visits. His most recent aspartate transaminase level (obtained within the past month) is 36 U/L and his alanine transaminase level is 23 U/L.
Thyroid: He has no known issues. When recently assessed, his thyroid stimulating hormone level was found to be 4.4 mIU/L.
- Ramadan is the ninth month of the year in the Islamic calendar. Individuals observing Ramadan will fast from sunrise to sunset during this month-long holiday.
- It is important to ask individuals if they are observing Ramadan because the Islamic sacred book, the Quran, states that there are groups of people who do not have to fast, especially if it puts their health at risk. This includes children, pregnant or breastfeeding women, the elderly, and anyone who might make themselves ill by fasting.
- Due to the change in eating schedule during Ramadan, consideration should be given to the timing of diabetes therapy in an effort to prevent hypoglycemia.