Protect Feet on DM

Protecting your feet

Whether or not you have diabetic neuropathy, there is a list of things to do to protect your feet

• Be careful to protect your feet from injury. Any minor injury may allow infection to set in, which could lead to gangrene and amputation. This means wearing shoes at all times.
• Look at your feet (with your eyes, or someone else can look if it's difficult for you to do): every day! If new problems are seen, such as a blister or red spot, telephone your doctor's office promptly for advice; stay off your feet until you get other advice.
• Break in new shoes slowly, so that they don't accidentally cause blisters.
• Keep several pairs of shoes at work, or in the car, so you can rotate among them if your feet feel tired.
• Every patient with neuropathy resulting in anesthesia should be under the care of a podiatrist for routine foot care, such as trimming nails and calluses. (In the U.S., Medicare will pay for this care every 60 days, if you have diabetes and are covered by Medicare health insurance.)
• And be sure the diagnosis is correct! (There are several other conditions that can also cause neuropathy). You should have an EMG/NCV study done, and some blood tests. Ask your diabetes specialist or neurologist if your personal physician isn't sure what to do (created by diabetesmonitor.com).
  

Menstruation, DM on Islam

Hormones control the menstrual cycle in a woman. These hormones can also affect your blood glucose. Many women notice more fluctuations in blood glucose at certain times in their monthly cycle, such as an increase in blood glucose a few days prior to the beginning of their period and then a decrease once the period begins. This increase usually occurs after ovulation and before menstruation. Changes are due to two hormones, estrogen and progesterone. When these hormones are at their highest level just before your period, they interfere with another important hormone, insulin, which may cause blood glucose to rise. Some women find their blood glucose rises considerably, while others do not notice a difference. In some women, blood glucose levels are lower before and during their periods. Each woman needs to discover her own pattern.

Often it is the fasting blood glucose before breakfast that tends to fluctuate the most in women with type 1 diabetes during the time just before a period begins. Adjusting your insulin often helps. For example, adjusting the intermediate acting insulin, NPH or Lente, taken before dinner or bed can help reduce high morning readings. When your period begins and your blood glucose levels go down, readjust your insulin back to its former level.

If you have type 2 diabetes and do not take insulin, remember regular exercise can lower blood glucose, therefore it is important to maintain physical activity during this time of the month. Besides better blood glucose levels, you will likely have more energy and have fewer unpleasant side effects from menstruation if you can be active on a regular basis.

If you notice fluctuations in your blood glucose and are not sure if these are related to your menstrual cycle, it is easy to find out. In your blood glucose record book, indicate when you start your period each month and watch for a relationship between the two.

Some women suffer more from premenstrual syndrome (PMS) than other women. It does not seem to be related to the type of diabetes that you have nor is it more common in diabetes. Women commonly experience moodiness, bloating, water retention and food cravings at this time. Food cravings for carbohydrates and fats combined with a reduction in activity may contribute to fluctuations in blood glucose (http://www.diabetesandislam.org).

Benefits DM

Most Muslims do not fast because of medical benefits but because it has been ordained to them in the Quran. The medical benefits of fasting are as a result of fasting. Fasting in general has been used in medicine for medical reasons including weight management, for rest of the digestive tract and for lowering lipids. There are many adverse effects of total fasting as well as so-called crash diets. Islamic fasting is different from such diet plans because in Ramadan fasting, there is no malnutrition or inadequate calorie intake. The caloric intake of Muslims during Ramadan is at or slightly below the national requirement guidelines. In addition, the fasting in Ramadan is voluntarily taken and is not a prescribed imposition from the physician.

Ramadan is a month of self-regulation and self-training, with the hope that this training will last beyond the end of Ramadan. If the lessons learned during Ramadan, whether in terms of dietary intake or righteousness, are carried on after Ramadan, it is beneficial for one's entire life. Moreover, the type of food taken during Ramadan does not have any selective criteria of crash diets such as those which are protein only or fruit only type diets. Everything that is permissible is taken in moderate quantities.

The only difference between Ramadan and total fasting is the timing of the food; during Ramadan, we basically miss lunch and take an early breakfast and do not eat until dusk. Abstinence from water during this period is not bad at all and in fact, it causes concentration of all fluids within the body, producing slight dehydration. The body has its own water conservation mechanism; in fact, it has been shown that slight dehydration and water conservation, at least in plant life, improve their longevity.

The physiological effect of fasting includes lower of blood sugar, lowering of cholesterol and lowering of the systolic blood pressure. In fact, Ramadan fasting would be an ideal recommendation for treatment of mild to moderate, stable, non-insulin diabetes, obesity and essential hypertension. In 1994 the first International Congress on "Health and Ramadan", held in Casablanca, entered 50 research papers from all over the world, from Muslim and non-Muslim researchers who have done extensive studies on the medical ethics of fasting. While improvement in many medical conditions was noted; however, in no way did fasting worsen any patients' health or baseline medical condition. On the other hand, patients who are suffering from severe diseases, whether diabetes or coronary artery disease, kidney stones, etc., are exempt from fasting and should not try to fast.

There are psychological effects of fasting as well. There is a peace and tranquility for those who fast during the month of Ramadan. Personal hostility is at a minimum, and the crime rate decreases. This psychological improvement could be related to better stabilization of blood glucose during fasting as hypoglycemia after eating, aggravates behavior changes.

Recitation of the Quran not only produces a tranquility of heart and mind, but improves the memory. Therefore, I encourage my Muslim patients to fast in the month of Ramadan, but they must do it under medical supervision. Healthy adult Muslims should not fear becoming weak by fasting, but instead it should improve their health and stamina (http://www.submission.org/ramadan-health.html).

Diabetes in Ramadhan

A Muslim may be devoted, liberal or secular; assess carefully how religiously devoted your patient is. Health professionals are also human and may have negative feelings about Muslims. Referral to another doctor will sometimes help both parties; take it or leave it, but do not proceed half-heartedly. Communication with the patient begins with respecting names. Even if they do not show it, many will be upset if you write Muslim as Moslem and Quran as Koran, if you use initials instead of full first and middle names (because these have religious connotations) and if you ask ‘what is your Christian name?’. These cultural issues, and the minutiae of diabetes management, have been discussed elsewhere. Here are ten practical points.

• Ramadan fasting improves diabetes by lowering the blood glucose and HbA1c because of fewer post-prandial peaks. Adjust medication if necessary
• Meditation and prayers tend to lower blood pressure. Adjust the dosage of antihypertensive drugs in a hypertensive patient
• Pork and non-halal meat are absolute taboos in Islam. Thus pork insulins, pork-based synthetic insulins, and beef (non-halal) insulins are unacceptable to devoted Muslims. Non-porcine synthetic (human) insulin should be given in preference. If a forbidden insulin is the only choice, a religious leader or doctor should be encouraged to mediate and reduce the patient's guilt feeling and spiritual pain. These advisers would use the doctrine of ‘the sanctity of life’, permissible in Islam. It means that life must be saved at all cost
• ‘Human insulin’ may be misunderstood by the patient as signifying manufacture from human flesh or pancreas, leading to non-compliance. Some non-westernized Asian and African Muslims do not understand diabetes as western people do. Explain that ‘human’ simply means ‘akin to human’
• In Ramadan, a person with type 2 diabetes can take a sulphonylurea at the end of the fast, with the evening meal started within 30 minutes. Advise not to miss the sehri (before sunrise) meal so as to avoid hypoglycaemia later in the day. Repaglinide (NovoNorm) can be particularly useful, since it need only be taken when a meal is eaten, therefore no change in drug therapy will be required in Ramadan. A meal must be eaten within 15 minutes
• The patient may concurrently be taking alternative medicine from a hakim (a Muslim healer) e.g. karela powder (an oral hypoglycaemic). Ask the patient, and adjust medication or advise accordingly
• Glycaemic foods should be taken into account. Muslim sweets taken in Ramadan, khir (rice pudding) and vermicelli are sugary and may necessitate a change in drug therapy. Savoury foods such as karela (a vegetable), onion and garlic are hypoglycaemic. Again, adjustment of medication or dietary tips may be needed
• Medical advice is sometimes ignored for religious reasons. Occasionally a devoted Muslim will say, ‘Allah will protect me’. He or she may not fear death or may even want to die so as to meet the Creator. Counsel the patient by saying ‘to see the doctor and comply with treatment is Prophet Mohammad's sunnat (precedent)’. To refuse would be a sin
• Article 9 of the 1998 Human Rights Act, which came into force on 2 October 2000, requires freedom of thought, conscience and religion. This has been incorporated in English and Scottish law and all general practitioners and hospital doctors are bound by it.

I hope that general practices and hospital clinics will use these notes as a starting point for drawing up guidelines according to local needs and circumstances (http://www.pubmedcentral.nih.gov).