Authors: Fatema Jawad  ( Editor-in-chief, JPMA. )
Sanjay Kalra  ( Department of Endocrinology, Bharti Hospital and B.R.I.D.E., Karnal, India. )

The holy month of Ramadan is an opportunity for purifying the body and the soul. It brings a spiritual and physical well-being through the daily fasts and prayers. This applies to all persons observing the ritual of fasting. Although people with ill-health are exempted from fasting, but most of those with chronic metabolic conditions such as diabetes, if in stable health can observe fasts. While fasting may lead to health benefits, inappropriate therapy has the risk of precipitating acute metabolic derangements in this population. This situation can be avoided and the person with diabetes can feel extremely comfortable with proper counseling and following the recommendations. It is an obligation on the diabetes care provider, to offer optimal diabetes support and therapy, which allows an improved glycaemic control and some loss of weight leading to a sense of improved health, not only during, but even after the month of Ramadan is over.
This special issue of the Journal of Pakistan Medical Association is focused on the various aspects of Diabetes and Ramadan care, ranging from physiology of fasting and risk stratification, to non-pharmacological and pharmacological management of diabetes. The contribution by the many experts has put together all steps for making this holy month comfortable and a cause for improvement in physical and mental health.
We encapsulate these principles in a mnemonic termed the 5 R\'s of Ramadan care. The 5 R\'s remind us of the essential element of diabetes care, and helps us to plan management not only during the holy month, but in general practice as well.

Respect

R reminds us to Respect the patient\'s attitudes, wishes and needs, and to take these in to account while planning therapy. From a Ramadan perspective, many believers may wish to fast, inspite of being medically unfit to do so. The diabetes care provider should explain the reasons for not fasting with empathy, while respecting the patient\'s thoughts. Ramadan offers a platform for practicing true person-centred care, in letter and spirit.¹

Risk Stratification

Risk stratification is an essential part of pre-Ramadan counseling, and is the second R. Detailed guidelines for such assessment have been discussed in this issue.² The degree of risk is described for various medical and surgical conditions, and helps the diabetes care provider to offer appropriate advice. Based upon risk stratification, and an empathic understanding of the person\'s attitudes and wishes, a shared decision can be arrived at regarding the feasibility of fasting.

Revision of Therapy

As the dietary and physical activity pattern changes drastically during Ramadan, glucose lowering therapy also has to be revised. Revision of therapy is the third R of Ramadan care. While drugs with glucose-dependent action profile, and low potential for hypoglycaemia, may not need change in dosage or timing of administration, those with a glucose-independent mechanism of action, and a relatively higher risk of hypoglycaemia will require modification of therapy. Revision of therapy is an art as well as a science and is discussed at length in this issue by various authors.^3-6
As diet is an important constituent of therapy, the necessary changes and proper timings should be explicitly explained. The details are included in this issue.⁷

Regular Follow Up

The fourth of the five Rs is Regular follow up. Regular consultation with the treating physicians is necessary before, during and after Ramadan, to ensure a safe and healthy fasting experience, Regular follow up allows the physicians to detect symptoms, signs or laboratory markers of metabolic dysfunction, in a timely manner. This issue discusses the need for regular monitoring during Ramadan in detail.⁸

Reappraisal of Strategy

Diabetes is a dynamic condition; its presentation, natural history, and response to treatment varies from individual to individual, and changes from time to time within the same person. Based upon clinical cues, and upon glucose monitoring trends, one must be prepared to modify management strategies as and when needed. Reappraisal of strategies, thus, forms the final R. Reappraisal should be done on a continuous basis before, - during and after Ramadan, so as to ensure optimal health and fasting experience for the person with diabetes.

The Five Rs And Their Relevance

We have discussed the five Rs in relation to Ramadan management. Respect for the patient, Risk stratification, Revision of therapy before Ramadan, Regular follow up, and Reappraisal of therapy are essential elements of Ramadan specific care.
The utility of this concept, however, extends to routine diabetes care as well. Person centred behaviour is a pre-requisite which is essential for every diabetes care provider. The CARES model provides a check list of soft skills which a diabetes counselor must develop.⁹ Respect for the patient is embedded in this model. Risk stratification is an activity which we perform unknowingly for every patient. Deciding between lifestyle and pharmacological management, between oral therapy and insulin, or conservative and invasive coronary management, are examples of risk stratification. The lessons learnt during pre-Ramadan risk stratification are useful in other clinical situations as well.
Revision of therapy is an activity which should take place at every clinical encounter. This is based upon a detailed history taking, comprehensive physical examination and focused investigations, Therapy should be revised in concordance with the person\'s dietary habits and physical activity patterns. Regular follow up helps in this process, and also facilitates Reappraisal of strategy. Every person with diabetes should have target goals for treatment, decided by shared decision making, based upon bio-psychosocial characteristics. Strategies should be put in place to achieve these targets. However, constant appraisal should be done to ensure that strategies being followed are appropriate and effective, Deviation from expected outcomes should prompt reappraisal and change of strategy. This includes not only glycaemia- lowering strategies, but those focused on blood pressure, lipids , weight and platelet function as well.

Teaching Tool

The five Rs act as a teaching tool for students of diabetology. The list acts as a mental check list for all practitioners of diabetology, to use during their clinical interactions. Every R must be addressed during each clinical encounter: adequate respect must be shown to the patient; a detailed workup done to assess risk; therapy revised if necessary; the patient requested to return for follow up; and a reappraisal done of therapeutic goals and strategies.


Conclusion

The five Rs are the pillars of diabetes care during Ramadan. If internalized, and followed in spirit, this concept should help achieve satisfactory diabetes care during as well as beyond, the period of Ramadan.


References

1. Kalra S, Megallaa MH, Jawad F. Patient-centered care in diabetology: From eminence-based, to evidence-based, to end user-based medicine. Indian J Endocr Metab 2012; 16: 871-2.
2. Al Arouj M. Risk stratification of Ramadan fasting in person with diabetes. J Pak Med Assoc 2015; 65(Suppl 1): S18-S21.
3. Islam N. Oral anti-diabetics in Ramadan. J Pak Med Assoc 2015; 65(Suppl 1): S37-S39.
4. Bajaj S. Newer antidiabetic drugs in Ramadan. J Pak Med Assoc 2015; 65(Suppl 1): S40-S43.
5. Kalra S, Jawad F. Insulin in Ramadan. J Pak Med Assoc 2015; 65(Suppl 1): S44-S46.
6. Kesavadev J. Fasting in Ramadan with an insulin pump. J Pak Med Assoc 2015; 65(Suppl 1): S47-S50.
7. Hossiain K, Zehra T. Diabetes and diet in Ramadan. J Pak Med Assoc 2015; 65(Suppl 1): S72-S75.
8. Jabbar A. Glucose monitoring during Ramadan. J Pak Med Assoc 2015; 65(Suppl 1): S51-S53.
9. Kalra S, Kalra B. A good diabetes Cousellor \'Cares\': Soft skills in diabetes counselling. Internet J Health 2010;11.