Diabetes Care During Hajj

Diabetes Therapy, Oct 2020

Diabetes mellitus affects over 463 million individuals worldwide. Religious activities such as the Hajj pilgrimage have a major impact on patients with diabetes mellitus, including increasing the risk of hyperglycaemia and hypoglycaemia. This increased risk is due to dietary changes and intense physical activity during pilgrimage while being on antidiabetic medications. Approximately 20% of the pilgrims with underlying illnesses who visit Mecca are diabetic, and complications, such as diabetic ketoacidosis, nonketotic hyperosmolar state, and fatigue/unconsciousness due to hypoglycaemia, have been observed among these patients. Diabetic patients are also at a high risk for foot complications and infections. To avoid any aggravation of the diabetes, a complete biochemical evaluation of the patient must be conducted before Hajj, and the patients must be provided contextualized educational guidance to avert these potential health challenges. This counselling should include the importance of carrying with them at all time their relevant medical history, summaries of the current treatment regimen and emergency snacks. In addition, to reduce the risk of hypoglycaemia, the dosage of insulin should be reduced in selected patients by 20% and that of sulfonylurea should be reduced as needed. Basal insulin and glucagon-like peptide 1 receptor agonists are associated with fewer complications and can be preferentially prescribed. Those patients with type 1 diabetes can continue with the use of insulin pump with suitable education prior to Hajj. For the prevention of foot problems, the use of padded socks and well-fitting shoes is recommended along with an insistence on not walking barefoot. After Hajj, the patient must be followed up, and necessary investigations must be made along with readjustment of insulin dosage in those patients for whom it was reduced. Until the pandemic situation abates, all diabetic patients should avoid making the Hajj journey.

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Diabetes Care During Hajj

Diabetes Ther (2020) 11:2829–2844 https://doi.org/10.1007/s13300-020-00944-5 REVIEW S. Shaikh Saifee Hospital, Mumbai, India H. Ashraf Rajiv Gandhi Centre for Diabetes and Endocrinology, Aligarh Muslim University, Aligarh, India K. Shaikh Royal Oman Police Hospital, Muscat, Oman H. Iraqi Service d’Endocrinologie et Maladies Métaboliques, Center Hospitalier Universaitaire Ibn Sina de Rabat, Rabat, Morocco M. Ndour Mbaye Cheikh Anta Diop University, Dakar, Senegal A. Kake National Non-Communicable Diseases Coordinator, Ministry of Health, Conakry, Guinea G. A. Mohamed Comprehensive Diabetes Center, Nairobi, Kenya S. Selim Department of Endocrinology and Metabolism, Bangabandhu Sheikh Mujib Medical University, Shahbag, Dhaka, Bangladesh M. Wali Naseri Internal Medicine, Kabul University of Medical Science, Kabul, Afghanistan I. Syed Victoria Hospital in Lusaka, Lusaka, Zambia J. A. K. Said Moi Teaching and Referral Hospital, Nandi Road Kapsoya Ainabkoi, Eldoret, Kenya S. A. Raza Shaukat Khanum Cancer Hospital and Research Center, Lahore, Pakistan H. Kassim Provincial Directorate of Health, Ministry of Public Health, Maputo, Mozambique H. Aydin Yeditepe University Hospital, Istanbul, Turkey A. Latheef Department of Medicine, Indira Gandhi Memorial Hospital, Malé, Maldives M. Beebeejaun The CURIS Clinic, Port Louis, Mauritius Diabetes Care During Hajj Shehla Shaikh . Hamid Ashraf . Khalid Shaikh . Hinde Iraqi . Maimouna Ndour Mbaye . Amadou Kake . Gaman Ali Mohamed . Shahjada Selim . Mohammad Wali Naseri . Imran Syed . Jamil Abdul Kadir Said . S. Abbas Raza . Hidayat Kassim . Hasan Aydin . Ali Latheef . Mehjabeen BeebeeReceived: July 21, 2020 / Accepted: October 2020 / . . Andrew . Sonak jaun E. Uloko D. 6,Pastakia Published online: October 15, 2020 Sanjay Kalra  The Author(s) 2020 ABSTRACT Diabetes mellitus affects over 463 million individuals worldwide. Religious activities such as the Hajj pilgrimage have a major impact on patients with diabetes mellitus, including increasing the risk of hyperglycaemia and hypoglycaemia. This increased risk is due to dietary changes and intense physical activity during pilgrimage while being on antidiabetic medications. Approximately 20% of the pilgrims with underlying illnesses who visit Mecca are diabetic, and complications, such as diabetic ketoacidosis, nonketotic hyperosmolar state, and fatigue/unconsciousness due to hypoglycaemia, have been observed among these patients. Diabetic patients are also at a high risk for foot complications and infections. To avoid any aggravation of the diabetes, a complete biochemical evaluation of the patient must be conducted before Hajj, and the patients must be provided contextualized educational guidance to avert these potential health challenges. This counselling should include the importance of carrying with them at all time their relevant medical history, summaries of the current treatment regimen and emergency snacks. In addition, to reduce the risk of hypoglycaemia, the dosage of insulin should be reduced in selected patients by 20% and that of sulfonylurea should be reduced as needed. Basal insulin and glucagon-like peptide 1 receptor agonists Diabetes Ther (2020) 11:2829–2844 2830 are associated with fewer complications and can be preferentially prescribed. Those patients with type 1 diabetes can continue with the use of insulin pump with suitable education prior to Hajj. For the prevention of foot problems, the use of padded socks and well-fitting shoes is recommended along with an insistence on not walking barefoot. After Hajj, the patient must be followed up, and necessary investigations must be made along with readjustment of insulin dosage in those patients for whom it was reduced. Until the pandemic situation abates, all diabetic patients should avoid making the Hajj journey. Keywords: Diabetes; Hajj; Hypoglycaemia; Pilgrim Hyperglycaemia; Key Summary Points The Hajj pilgrimage poses certain challenges to those persons living with diabetes. A comprehensive pre-pilgrimage medical checkup in combination with focussed health education is necessary to ensure a safe pilgrimage. Appropriate attention must be paid to diet, glucose monitoring, dose titration, maintenance of fluid balance and foot hygiene. Understanding these aspects of diabetes care will help ensure a fulfilling pilgrimage for the believers who undertake the Hajj. A. E. Uloko Aminu Kano Teaching Hospital–Bayero University Kano, Kano, Nigeria S. D. Pastakia Indiana University–Kenya Partnership, Purdue University, West Lafayette, IN, USA S. Kalra (&) Bharti Hospital, Karnal, Haryana, India e-mail: DIGITAL FEATURES This article is published with digital features, including [list digital features available e.g. a summary slide and video abstract], to facilitate understanding of the article. To view digital features for this article go to https://doi.org/10. 6084/m9.figshare.13050551. INTRODUCTION Epidemiology of Diabetes Mellitus According to the International Diabetes Federation prevalence estimates for 2019, diabetes mellitus (DM) affects over 463 million individuals worldwide, of whom 90% have type 2 diabetes mellitus (T2DM) [1]. The prevalence of DM has significantly increased over the last two decades, with the maximum rise noted in regions of the Middle East and North Africa, particularly in Saudi Arabia [1]. Populationbased studies have indicated that Saudi Arabia ranks highest in terms of prevalence of diabetes, with 17.7% of the general population having this metabolic disease [2]. The prevalence of diabetes is high in several nations with large Muslim population, such as Pakistan, Indonesia, Egypt, Bangladesh and India, and all of these countries rank amongst the top ten countries in the world in terms of diabetes prevalence [3]. Overall, 148 million Muslims have been estimated to be diabetic based on an analysis of worldwide data [3]. Religious Commitments of Hajj Hajj is the fifth pillar of Islam and is considered obligatory for all Muslims provided they are in sufficiently good health to undertake the journey [4]. ‘Hajj’ is an Arabic word for pilgrimage and is performed at the holy cities of Mecca and Medina where over 2.5 million pilgrims gather annually to perform the religious ceremonies of Hajj, which last between 5 and 15 days for most pilgrims, but may extend to 45 days for some [5, 6]. In 2019, 24,89,406 pilgrims performed Hajj, based on the sites’ official website registers. Diabetes Ther (2020) 11:2829–2844 In light of the worldwide spread of coronavirus disease 2019 (COVID-19), the Hajj can be a high-risk undertaking, especially for patients with DM and other comorbidities [7]. Patients with DM wanting to undertake the Hajj journey have unique needs pertaining to their religious practices and health status. This necessitates differential care and attention in order to prevent possible complications that could arise during religious activities. Both healthcare professional-orient (...truncated)


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Shehla Shaikh, Hamid Ashraf, Khalid Shaikh, Hinde Iraqi, Maimouna Ndour Mbaye, Amadou Kake, Gaman Ali Mohamed, Shahjada Selim, Mohammad Wali Naseri, Imran Syed, Jamil Abdul Kadir Said, S. Abbas Raza, Hidayat Kassim, Hasan Aydin, Ali Latheef, Mehjabeen Beebeejaun, Andrew E. Uloko, Sonak D. Pastakia, Sanjay Kalra. Diabetes Care During Hajj, Diabetes Therapy, 2020, pp. 2829-2844, Volume 11, Issue 12, DOI: 10.1007/s13300-020-00944-5