Modern medicine and religious traditions may seem unlikely bedfellows. But in the case of diabetes, new drug technologies are helping many people participate in rigorous religious fasting.
Most of the world's religions include some form of fasting, including the 25-hour Jewish Yom Kippur next month to Islam's month-long Ramadan, currently under way and ending Sept. 9.
Until even five years ago, many diabetics would be urged by their doctors not to forgo food and water - not to mention all oral medications, which Islam, for instance, would disallow during Ramadan - for long periods of time.
"Now, there's no reason most diabetics can't fast," says Joseph Shaban, an endocrinologist in Windsor, Ont. "We've got the tools - medications are so much more effective and we can minimize the risks of low sugar."
The decision to fast is fraught with thorny issues for those with chronic medical conditions, the elderly, the very young, pregnant women and nursing mothers.
Toronto mother Mei Qu, a practising Baha'i, says she's missed two years of her faith's 19-day fast in March because of to pregnancy and nursing her now 20-month-old. But she says she was able to join her husband in prayer and in the social gatherings of the celebration. And, in her own way, Ms. Qu says she was observing the message of the fast.
"The fast is about spiritual regeneration and I was creating a life," she says. "I didn't miss out on that at all." That said, she was also very respectful of others. "I'd go upstairs to eat."
Dr. Shaban was once faced with a pregnant patient who was determined to fast for Ramadan. He convinced the patient to try to reverse her day: rest during the day, eat well, drink lots of water and take her maternity vitamins in the evening. And not to miss the traditional early morning light meal at about 4 a.m.
"They're going to do it and I have to make sure no harm comes to them," he says. "I have to have empathy for the patient."
Ottawa endocrinologist Shajia Khan says that although most religions are very lenient that ill, elderly, very young, pregnant or nursing people can opt out of fasting, the social pressure can push some to ignore their own health.
With her diabetic patients, she discourages fasting for those with serious diabetes and insulin dependence and pregnant women. Even so, she'd rather a patient confess that they are going to ignore her advice so she can advise them. "There are some people who are just adamant so we do our best and help them with adjusting their insulin."
The drive to participate is strong. In his practice, Dr. Shaban says that he can help about 80 per cent of diabetic patients who want to fast for religious reasons succeed. He can adjust a patient's medications, including insulin and diuretics, to the schedule of the fast so that they are most effective while a patient is eating. New formulations of insulin allow a patient to have use a slow-release version throughout the day, then a different form along with the evening meal to help them process it.
"It gives diabetics a freedom they were never able to enjoy in the past," says Dr. Shaban, the chief of medicine at the Windsor Regional Hospital and the chair of the Ontario Medical Association's endocrinology and metabolism section.
Many fasts forbid eating and drinking from sunrise to sunset, so doctors will also remind patients about the best foods to eat during early-morning and late-evening meals.
Ten years ago, he says, many of these patients would simply have been told not to fast because of the risk of low blood sugar reactions, the most severe of which is a diabetic coma.
Ahmad Abou Hassan is a diabetic who has not missed a Ramadan since he was five years old. He has an appointment with Dr. Shaban Thursday, but he is currently using the strategies Dr. Shaban has suggested in the past few years, including using his medications when he eats in the early morning, between 4 and 5 a.m. and after sunset with dinner.
"Fasting doesn't affect me. I have no problems, so far," the 59-year-old Windsor man says. "I'm feeling good."
Enabling diabetics to fast is not only about helping them participate in their religions. The experience can also be a healthy reset button. Patients who struggle with obesity can benefit from the willpower needed to fast. One of Dr. Shaban's patients has already lost 10 pounds while fasting for Ramadan.
"After a few weeks it becomes easier to say no to that éclair in the window," he says.
Other benefits can include becoming less dependent on medication. Cholesterol and triglyceride levels can go down. Blood sugars improve. And others have reduced swelling in the legs.
Imam Abdullah Hammoud of the Al-Hijra Mosque in Windsor is a diabetic who is currently fasting for Ramadan and being treated by Dr. Shaban.
He has also found that moving his medications to the two mealtimes doesn't affect his blood sugar levels. Sometimes he sleeps right through the early morning meal and even then his blood sugar remains stable. If it faltered and he felt ill, the religious leader says he'd be violating the spirit of the fast if he didn't stop and eat or drink something.
"According to our faith, if the fast is hurting us, it is prohibited," the 54-year-old says. Instead, he says, he enjoys losing a little weight and seeing his cholesterol level dip. He says that many Muslims experience weight loss because they are encouraged to eat modest meals when they do eat.
But there are times when religious feeling overcomes doctors' orders. Some fasting purists refuse to test their blood sugars because it intrudes on the body, so Dr. Khan reminds them that feeling faint or dizzy is a sign of low blood sugar and they should consider breaking the fast. She reminds Muslim patients that they can make up any missed days after the end of Ramadan.
Mr. Hammoud also has suggestions for members who are struggling with faith versus health. He tells those who can't fast to participate in prayers and encourages them to donate money toward feeding the needy throughout the period.