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REVIEW
Fasting, Diabetes, and Optimizing Health Outcomesfor Ramadan Observers: A Literature Review
Hadi A. Almansour . Betty Chaar . Bandana Saini
Received: November 23, 2016 / Published online: February 8, 2017� The Author(s) 2017. This article is published with open access at Springerlink.com
ABSTRACT
Introduction: Globally, and in Australia, dia-betes has become a common chronic healthcondition. Diabetes is also quite prevalent inculturally and linguistically diverse pockets ofthe Australian population, including Muslims.There are over 90 million Muslims with diabetesworldwide. Diabetes management and medica-tion use can be affected by religious practicessuch as fasting during Ramadan. During Rama-dan, Muslims refrain from oral or intravenoussubstances from sunrise to sunset. This may leadto many potential health or medication-relatedrisks for patients with diabetes who observe thisreligious practice. This literature review aimedto explore (1) health care-related interventionsand (2) intentions, perspectives, or needs ofhealth care professionals (HCPs) to provideclinical services to patients with diabetes whilefasting during Ramadan with a view to improvehealth outcomes for those patients.Methods: Using a scoping review approach, acomprehensive search was conducted. Data-bases searched systematically included PubMed,
Medline, Embase, and International Pharma-ceutical Abstracts. Studies published in Englishthat described interventions or intentions toprovide interventions regarding diabetes andRamadan fasting were included.Results: Fourteen published articles that metthe inclusion criteria were retrieved and contentanalyzed. Of those, nine intervention studiesregarded diabetes management education. Fivestudies described professional service intention,four of which were related to the role of phar-macists in diabetes management in Qatar, Aus-tralia, and Egypt, and one French studyexamined the general practitioners’ (GPs)experiences in diabetes management for Rama-dan observers. The intervention studies hadpromising outcomes for diabetes managementduring Ramadan. Effect sizes for improvementin HbA1c post intervention ranged widely from-1.14 to 1.7. Pharmacists appeared to be willingto participate in programs to help fastingpatients with diabetes achieve a safe therapeuticoutcome. Service intention studies highlightedpharmacists’ and GPs’ need for training prior toproviding services from a clinical as well ascultural competence perspective.Conclusion: Interventions research in this arearequires robustly designed and structured inter-ventions that can be tested in different contexts.This literature review revealed many gaps regard-ing diabetes management in Ramadan. Healthprofessionals are willing to provide services forfasting diabetes patients, but need upskilling.
Enhanced content To view enhanced content for thisarticle go to http://www.medengine.com/Redeem/4887F06060CC1453.
H. A. Almansour (&) � B. Chaar � B. SainiFaculty of Pharmacy, University of Sydney, Sydney,Australiae-mail: halm7156@uni.sydney.edu.au
Diabetes Ther (2017) 8:227–249
DOI 10.1007/s13300-017-0233-z
Keywords: Fasting; HbA1c; Hypoglycemia;Pharmacist; Ramadan; Type 1 diabetes; Type 2diabetes
INTRODUCTION
Internationally, the prevalence of diabetes isapproximately 8.3%; 382 million people livewith diabetes [1]. Of these, nearly 90 million areMuslims [2]. Diabetes is also increasinglybecoming a common disease among the Aus-tralian adult population. In 2011–12, forexample, 4.7% of the Australian populationwere reported to have type 2 diabetes (T2D) [3].Diabetes is particularly prevalent in culturallyand linguistically diverse (CALD) Australians.Many of these CALD populations follow differ-ent religious beliefs. Islam is one of the keyreligions followed by CALD populations. Forexample many of those who have migrated toAustralia from the Indian subcontinent, centraland far east Asian countries (Indonesia/Malay-sia), Europe, and from the middle-eastern andNorth African regions are Muslims [4]. Therehas been an estimated 69% increase in theAustralian Muslim population from 2001 to2011, with the total current number of Muslimsbelieved to be approximately 476,300 [5].Although the prevalence of diabetes in Aus-tralian Muslims is not known directly, indirectmarkers point to the fact that diabetes may befairly common in this population. Studiesindicating, for example, that Australian womenand men born in the Middle East or NorthAfrica were 2.4 and 3.6 times more likely tohave diabetes than those who were born inAustralia [6]. Given that about 42% of Aus-tralian Muslims are of North African or MiddleEastern origin, these data suggest the possibilitythat diabetes may be quite prevalent in Aus-tralian Muslims [4]. This population group isalso likely to have socio-religious practices thatmay impact on their beliefs about health andhealth management practices [6]. Religiousfasts, such as Ramadan, are a key example ofthis issue.
Fasts may influence the body’s homeostaticrhythms and in those taking chronic medica-tions, fasts may upset established
pharmacokinetic and pharmacodynamics dis-position patterns of medications [5–7]. Fastinghas the potential to affect glucose control ofpatients who have diabetes mellitus and it candisrupt the actions of antidiabetic medications[7]. Ramadan is a well-known fast observed byMuslims. Ramadan occurs in the ninth monthof the lunar calendar in Islam and lasts 29–-30 days [8, 9]. Fasting in Ramadan is one of theprincipal pillars of Islam; it requires Muslims tofast during daylight hours, abstaining from allfood and drink, as well as substances, such asmedicines, taken orally or intravenously[10, 11]. Fasting people usually have a post-fastmeal (Iftar) after sunset and a pre-fast mealbefore sunrise (spelt varying in English asSohour, Suhoor, Suhur, or Sehri) [8, 10]. Theabsolute refraining from food and drinkbetween sunrise and sunset can lead to disrup-tion of homoeostasis [10]. It is worthwhile toconsider the impact of fasting on the health ofRamadan observers, as these observers havebeen reported to have higher prevalence ofdiabetes. There are, for example, more than50 million Muslims worldwide who observeRamadan although they live with diabetes [12].For instance, an epidemiological study mappingdiabetes patients observing the Ramadan fast(n = 12,914) in 13 Muslim countries indicatedthat almost 79% of patients with T2D observedthe fast of Ramadan [12].
Diabetes is actually the most common illnessstudied with regard to Ramadan [13–18]. Fast-ing has the obvious potential to disrupt diabetesmanagement as a result of the reduced food,drink, and medication intake during certainhours [17]. The practice of observing themonth-long fast can affect glucose control [19].This could lead to avoidable health problems.One of the potential adverse effect risks of tak-ing antidiabetic medications and fasting can behypoglycemia. Other issues that may occurinclude hyperglycemia, hyperglycemic-hyper-osmolar state, and diabetic ketoacidosis [13, 20].Several studies have attempted to document theeffect of fasting on diabetes. A prospectiveclinical trial was conducted in Iran to examinethe impact of Ramadan fasting on glycemiccontrol in T2D patients (n = 88). The trialreported that glycemic control deteriorated
228 Diabetes Ther (2017) 8:227–249
significantly among T2D patients who opted tofast during Ramadan. Nonetheless, hemoglobinA1c (HbA1c) reduced significantly a monthafter Ramadan from 9.4 ± 2% to 8.4 ± 2.5%(p\0.001) [21]. On the other hand, a recentreview highlighted that in insulin-dependentpatients with diabetes, severe hyperglycemiaand ketoacidosis were insignificant concerns,and only minor hypoglycemic episodes wereevident in this population, when they reportedobserving Ramadan [22].
Several studies have illustrated the impor-tance and positive effects of regular glucosemonitoring, dietary counselling, drug dosageand timing alteration, and patient educationduring Ramadan [23, 24]. The InternationalGroup for Diabetes and Ramadan (IGDR) con-sensus diabetes management recommendationsduring Ramadan (2015 update) reported byIbrahim et al. suggest several recommendationsfor adverse event prevention strategies duringRamadan as shown in Table 1 [24]. Also guide-lines for medication management duringRamadan have been suggested by a few groups,and key points are summarized in Table 2.
Ahmedani et al. demonstrated in a multi-center prospective study (n = 682 patients withdiabetes) that most participating patients fastedwithout any serious acute adverse events duringRamadan when the recommendations men-tioned above were provided [25]. In this study,
for example, 91% of fasting patients had theirdrug dose/timing altered, and physical activitypatterns were downgraded from moderate/heavy to lighter levels of exercise; changes wereoverseen by medical practitioners [25].
One of the health professionals that couldplay a key role in optimizing the health of thosewith T2D observing Ramadan may be commu-nity pharmacists. Pharmacists are usually con-sulted far more often than physicians. They arealso usually available for consultation withoutappointments, and in most cases health con-sults are provided without a fee for service.Robust data from multisite trials suggest thatpharmacists’ intervention for patients withdiabetes can improve clinical and humanisticoutcomes for patients [26–31]. However, therehas not been much research conducted in Aus-tralia on fasting patients with diabetes, nor arethere specific medical/allied health professionalguidelines for the management of T2D inpatients observing Ramadan in Australia. Thefirst exploratory study into pharmacists’ per-spectives about their role in care of patientswith diabetes observing Ramadan was con-ducted in 2015 [32]. Findings of this qualitativework indicated that pharmacists do not proac-tively provide care for T2D Ramadan observers,but are keen to do so if supported by trainingand practice frameworks [32]. To developguidelines and interventions to optimize
Table 1 Recommendations to prevent diabetes-related adverse events risks during Ramadan (adapted from Ibrahim et al.[24])
Recommendations to prevent adverse events risks
Blood glucose monitoring several times a day depending on treatment regimen for a month prior to Ramadan
Consultation with HCPs for changing medications based at least 1 month before Ramadan begins
Avoiding large pre-dawn (Sohour) meals
Avoiding vigorous physical activities during fasting time
Recording blood glucose readings regularly during Ramadan to determine the occurrence of hypoglycemia
Breaking the fast and eating snacks immediately if hypoglycemic symptoms appear. Further recommendations for
hypoglycemia treatment involve consuming 15 g of carbohydrates such as half a cup of orange, apple juice or regular
soda, three or four glucose tablets, a table spoon of honey or sugar, five or six hard candies, a cup of milk, or a serving of
glucose gel
HCP health care professional
Diabetes Ther (2017) 8:227–249 229
Table2
Medicationadjustmentsuggestionsduring
Ram
adan
(adapted
from
Karam
atet
al.[49]andAliet
al.[2])
Typeof
antidiabetic
medication
Dosebefore
Ram
adan
Medicationadjustmentsuggestion
sNote:
Soho
urim
pliesa.m.do
seandIftarim
pliesp.m.do
se
Metform
in500mgtds
Thisneedsto
bechangedto
1000
mgtakenat
sunset
meal(Iftar)and500mgat
predaw
nmeal(Sohour)
Short-acting
sulfo
nylurea
Forexam
ple,gliclazide
80mgbd
Changeto
gliclazide
80mgat
Iftar,40
mgat
Sohour
Forexam
ple,gliclazide
80mga.m.?
40mgp.m.
Changeto
gliclazide
80mgat
Iftar,40
mgat
Sohour
Long-acting
sulfo
nylurea
Forexam
ple,glim
epiride4mgod
Switch
torepaglinideor
short-acting
sulfo
nylurea,ifpossible,otherwisedoseshould
betakenwithIftar
DPP
-4inhibitors
Forexam
ple,vildagliptin50
mgbd,sitagliptin
100mgod,saxagliptin5mgod,and
linagliptin
5mgod
Nochange
indose
isrequired
butcautionaround
dehydrationandsyncopein
warm
coun
triesisadvised.
Patientsarealso
requestedto
paycloseattentionfor
anysignsof
ketoacidosisandbe
provided
withketone
testingkits
Glucagon-likepeptide
1agonist
Forexam
ple,liraglutide
1.2mgod,exenatide
10lg
bd,lixisenatide20
mgod,exenatide
qw
Withexenatideitshould
beensuredthat
theduration
betweenthedaily
dosesis
[6h.
Thismay
beaffected
whenduration
offastis[18
h
Sodium
–glucose
co-transporter
2
inhibitors
Forexam
ple,dapagliflozin,canagliflozin
Nochange
needsto
bemadeforthedosesof
thistype.H
owever,p
atientsshould
payattentionto
anysign
ofketoacidosisandthey
canbe
givenketone
kits.A
lso,
cautionisrequired
regardingsyncopeanddehydrationin
warm
coun
tries
Insulin
Long-acting
(basal)insulin
,e.g.,glargine
Long-acting
insulin
doseshould
bereducedby
20%andtakenatIftar,e.g.,glargine
dose
canbe
reducedfrom
20to
16U
andtakenwitheveningIftarmeal
Rapid-acting(m
eal-tim
e)insulin
,e.g.,Novorapid/
Hum
alog
10U
tdswithmeals
Lun
chtimedosecanbe
omittedandinsulin
canbe
takentwicedaily
withmealsat
Sohour
andIftar,e.g.,N
ovorapid/H
umalog
10U
withSohour
andIftar
Mixed
insulin
,e.g.,Novom
ix30–3
0U
a.m.and
20U
p.m.
Considerreversingdosesso
thattheusualm
orning
doseistakenatIftarandhalfof
theusualevening
doseistakenatSohour,e.g.,Novom
ix30–1
0U
atSohour
and
30U
atIftar
Mixed
insulin
,e.g.,Hum
alog
Mix
25–2
0U
a.m.
and20
Up.m.
Forexam
ple,Hum
alog
Mix25–1
0U
a.m.and
20U
p.m.
Mixed
insulin
,e.g.,Hum
ulin
M3–
32U
a.m.and
24U
p.m.
Forexam
ple,Hum
ulin
M3–
12U
a.m.and
32U
p.m.
tds3times
aday,bd
twiceaday,od
once
aday,qw
once
aweek
230 Diabetes Ther (2017) 8:227–249
diabetes management during Ramadan in Aus-tralia, an important step would be to utilizeresearch from international settings. Interna-tional reviews have been conducted to investi-gate pharmaceutical interventions (e.g.,medicine related trials) for patients observingRamadan, but none have looked at educationalor supportive interventions provided by healthprofessionals [1]. This literature review aimed toexplore (1) health care-related interventionsand (2) intentions, perspectives, or needs ofhealth care professionals (HCPs) to provideclinical services to patients with diabetes whilefasting during Ramadan with a view toimproving health outcomes for those patients.
METHODS
Description of Search Strategyfor Literature Review
Given the diverse nature of interventionsexpected, a scoping review method was appliedfor the conduct of this review. A scoping reviewgenerally maps out the literature to address abroader research question and clarifies the keyconcepts of a research area. It helps identifygaps in the research topic based on the availableliterature [33]. Studies exploring the effects offasting on patients with diabetes were searchedin various online libraries and databases such asPubMed, Medline, CINAHL, EMBASE Interna-tional Pharmaceutical Abstracts, andCOCHRANE. The search initially used MeSHterms and keywords in combination, such as‘‘[fasting OR Ramadan], [diabetic patients ORdiabetes], [fasting in Australia OR Ramadan inAustralia], [diabetes AND Ramadan], [diabetesAND Fasting], [diabetic patients AND Rama-dan], [diabetic patients AND Fasting], [diabeticpatients AND Fasting AND health care profes-sionals (HCPs)],’’ which yielded 1469 articles.Filtration was then applied by using keywordsand Boolean operands, e.g., ‘‘Fasting duringRamadan AND Diabetic patients,’’ which resul-ted in 592 articles. The search was furtherrefined by using key terms in combination‘‘Fasting AND diabetic patients.’’ The referencelists of articles at this stage were scoured for
further relevant articles. Duplicate removal wasfollowed by application of inclusion/exclusioncriteria to all identified abstracts by the researchteam. Selected articles were read by the first andlast author and data extracted using a tabularframework.
Exclusion and Inclusion Criteria
Inclusion CriteriaOnly articles published in the English languagefrom 1986 to August 2016 were selected for thereview. The period spanned 30 years as thereappeared to be limited research published onthe topic, so a broader period was selected toencompass as much research as possible in thescope of our review. The articles selected werereviewed to ensure that they were originalstudies, and that they were published inpeer-reviewed journals. Interventions deliveredby all health professionals were included in thereview, with a specific focus on those deliveredby pharmacists. Intervention research isinformed by needs analysis conducted pre-in-tervention. A key component of needs analysesincludes the willingness of providers to engagein intervention delivery. Therefore, researchconforming to this description was also inclu-ded in the review, in addition to interventiontrials.
Exclusion CriteriaSeveral exclusion criteria were applied. Forexample, research pertaining to other healthconditions or fasts other than Ramadan wasexcluded from selection. Literature reviews,consensus guidelines, and case or meetingreports were also excluded.
RESULTS
A total of 596 articles were extracted from theoriginal search. Upon further refining, as shownin Fig. 1, 14 relevant articles were obtained andincluded within this literature review. The studyauthor, year, country, research methods, samplesize, response rate, and the outcomes of thestudy were tabulated (Tables 3, 4). These 14
Diabetes Ther (2017) 8:227–249 231
studies had utilized heterogeneous researchmethods including cross-sectional observa-tional surveys or qualitative data gathering. Inmost studies data were collected via self-ad-ministered survey instruments, focus groupssessions, and face-to-face or telephoneinterviews.
Of the 14 articles, nine involved interven-tion studies regarding diabetes managementeducation, and a further four studies were rela-ted to the role of pharmacists in providing orbeing willing to provide diabetes managementinterventions in Qatar, Australia, and Egypt.A French study that examined the GPs’
experiences in diabetes management for Rama-dan observers was also included in the review.
Intervention-Based Studies
These studies led to safer fasting during Rama-dan, weight loss, and improved glycemic con-trol among the intervention group. The careprovided in some of the interventions, however,was not standardized; and some studies did notattempt to quantify the effect of interventions.
None of these studies had a robust designand response rates were either low or not pro-vided. Power calculations were not reported in
Records iden�fied through database searching
(n = 562)
Screen
ing
Includ
edEligibility
Iden
�fica�o
n
Addi�onal records iden�fied through other sources
(n = 34)
Records a�er duplicates removed (n = 385)
Records screened (n = 385)
Records excluded (n = 318)
i.e. 242 were excluded from the title and 76 were excluded after reading the
abstracts
Full-text ar�cles assessed for eligibility
(n = 67)
Full-text ar�cles excluded, (n = 53)
Reasons include: • Did not assess fas�ng
pa�ents’ interven�ons in Ramadan (n=34)
• Expert opinion (n=11)• Literature review (n=7)
Studies included in scoping review
(n = 14)
Fig. 1 Flow chart of the search strategy
232 Diabetes Ther (2017) 8:227–249
Table3
Characteristics
ofincluded
intervention
s
References
Cou
ntry
Metho
dsSampling
Participants
Respo
nse
rate
Results/outcomes
Bravisetal.
[39]
London,
UK
Parallelcontrolgrouptrial
testingtheeffectsof
the
READ
educationprogram
ondiabetesoutcom
es(i.e.,weight
andhypoglycem
icepisodes
during
Ram
adan),which
was
delivered
afortnightto
amonth
before
Ram
adan
bydoctors,specialistnu
rses,
dieticians,and
linkworkers
Patientswithdiabetes
who
wereobservingRam
adan,
self-selected
(i.e.,responded
topostersor
advertisem
ents)
orreferred
byGPs
tothe
study.The
intervention
was
a2-heducationprogram
that
included
educationon
mealplanning,p
hysical
activity,glucose
monitoring,
hypoglycem
ia,d
osage,and
thetimingof
medications
111patientswithT2D
,planning
tofastduring
Ram
adan—57
patients
receivingtheintervention
and54
ascontrols.
They
wererecruitedfrom
public
venu
esincludinglocal
mosques
orreferred
bytheir
GPs
NM
HbA
1creductionwas
sustainedin
theintervention
group(-
0.13%,p
=0.07),
whileitincreasedby
0.33%
(p=
0.03)in
thecontrol
groupat
12months(effect
size,d
=0.44).There
was
ameanweightlossof
0.7kg
afterRam
adan
inthe
intervention
group
(p\
0.001)
vs.0
.6kg
mean
weightgain
inthecontrol
group(p\
0.001).
Significant
decrease
intotal
hypoglycem
icepisodes
was
observed
intheintervention
group,
whereas
therewas
4-fold
increasesin
controls
(p\
0.001)
during
Ram
adan
Fatim
etal.
[38]
India
Prospectiveobservationalstudy
testingtheeffect
ofa
coun
selling
andeducation
program
ondiabetes.
Outcomes
measuredusinga
questionnaire.Focussed
onkeyRam
adan-related
health
behaviorsandevents
Purposivesampleinvolving
patientswho
visiteda
hospital’soutpatient
clinic
before
Ram
adan
in2009.
Theywereprovided
astructured
education
program
2–4weeks
priorto
Ram
adan,and
know
ledge
outcom
esandadverseevent
diarieswerecollected
post-Ram
adan
96patientswithT2D
intend
ingto
fastduring
Ram
adan
NM
Awarenessscores
increased
significantlyfrom
6.81
±1.63
pre-Ram
adan
to9.15
±0.95
post-Ram
adan
(effectsize,d
=1.7).L
ess
adverseeffectsandmorefasts
werekept
than
lastyear.T
hemaxim
alincrease
ofaw
arenessof
26%
from
baselin
ewas
seen
inthe
patientsaged
between40
and60
years
Diabetes Ther (2017) 8:227–249 233
Table3
continued
References
Cou
ntry
Metho
dsSampling
Participants
Respo
nse
rate
Results/outcomes
Siaw
etal.
[35]
Singapore
Prospectivestudythat
focussed
oncoun
selling
byHCPs,and
medicationdose
adjustment.
Studyquestionnaireand
HbA
1ccompleted
bypatients
before,d
uring,andafter
Ram
adan;patientsrecruited
from
anoutpatient
endocrine
clinic
AllMuslim
patientsattend
ing
thisoutpatient
endocrine
clinicwho
wereover21
years
ofagewithT2D
andwho
fasted
forat
least10
days
during
Ram
adan
153patientswho
completed
thestudy
61%
Significant
reductionin
HbA
1cfrom
8.9±
2.0%
before
Ram
adan
to8.6±
1.8%
during
Ram
adan
(p\
0.05)(H
bA1c
effect
size,d
=0.16).Significant
improvem
entsin
HbA
1calso
observed
insubgroups
where
thedose
ofantidiabeticwas
adjusted
during
Ram
adan
(p\
0.001)
McEwen
etal.
[36]
Egypt,Iran,
Jordan,and
SaudiArabia
Prospectivestudyof
patients
withT2D
attend
ingclinics
(n=
12)who
received
individualized
educationfrom
clinicstaff.Toexplore
whether
individualized
educationbefore
Ram
adan
canlead
toasaferfastfor
T2D
patients.E
ach
participantreceivedan
average
twosessions
of0.5–
1h
individualized
face-to-face
educationsessions
cond
ucted
bydiabetes
specialistnu
rses,
dieticians,o
rtrainedlin
kworkers.T
heeducation
sessions
delivered
before
and
during
Ram
adan
covered
issues
includingphysical
activity,m
ealplanning,b
lood
glucosemonitoring,andacute
metaboliccomplications
Purposivesamplingof
T2D
patientsrecruitedfrom
12clinics
774patients—515represent
theintervention
groupwho
received
individualized
educationthat
was
delivered
one-to-one
orin
agroupin
thepatient’s
preferred
language.2
59(control
group)
received
usualcare
andthey
weregivenandan
Englishor
Arabiccopy
ofthe2010
American
Diabetes
Association
(ADA)
guidelines
diabetes
managem
entwhileobserving
theRam
adan
fast
NM
The
intervention
groupwere
morelikelyto
adjusttheir
diabetes
treatm
entplan
during
Ram
adan
(97%
vs.
88%,p
\0.0001)andwere
ableto
self-monitor
their
bloodglucoseat
leasttwice
daily
during
Ram
adan
(70%
vs51%,p
\0.0001).They
also
have
enhanced
their
know
ledgeabout
hypoglycem
icsignsand
symptom
s(p
=0.0007).It
resultedin
reducedbody
massindex(BMIeffect
size,
d=
0.43)andglycated
hemoglobinof
the
intervention
groupduring
Ram
adan
comparedto
controlgroup
(HbA
1ceffect
size,d
=0.66)
234 Diabetes Ther (2017) 8:227–249
Table3
continued
References
Cou
ntry
Metho
dsSampling
Participants
Respo
nse
rate
Results/outcomes
Susilparat
etal.
[34]
Thailand
Prospectivestudyto
investigate
theeffectivenessof
contextual
educationfor
self-managem
entin
patients
withT2D
during
Ram
adan.
The
outcom
esweremeasured
afterRam
adan
using
interviewswithpatients,
weightandwaist
measurements,blood
pressure,
andbloodtests
Purposivesamplingof
T2D
patientsaged
35–6
5years
old,
withno
diabetes-related
complications
such
askidn
eyandheartdiseases,and
capableof
readingand
writing
inThai
90T2D
patients—62
patients
wereeducated
priorto
Ram
adan
indiabetes
managem
entandhowto
adjusttheirantidiabetics
accordingly.28
patients
received
usualcare
NM
Nosevere
hypoglycem
iaevents
werereported
bythe
experimentalor
control
group.
There
was
adecrease
inthenu
mberandportion
ofpatientswith
hypoglycem
icsymptom
sin
theexperimentalgroup
comparedto
thecontrol
group(p
=0.013)
(HbA
1ceffect
size,d
=0.14
and
basicknow
ledgeabout
diabetes
effect
size,
d=
0.34).Sw
eetenedfood
consum
ptionwas
reducedin
theexperimentalgroupafter
Ram
adan
(p=
0.002)
Ahm
edani
etal.
[23]
Karachi,P
akistan
Prospectivestudyto
findoutthe
effectsof
glucosemonitoring,
drug
dosage
andtiming
adjustments,p
atients’
coun
selling
andeducation
regardingdiet
and
complications
that
might
occurwhilefastingduring
Ram
adan.T
woeducational
sessions
werecond
ucted
separatelywitheach
patient
onaone-to-one
basis,onewas
cond
uctedby
adoctor
(lasted
for20–2
5min)andtheother
byadietician(lastedfor
20–2
5min)
Purposivesamplingfrom
the
outpatient
departmentof
the
BaqaiInstituteof
Diabetology
and
End
ocrinology
110patientswithdiabetes—
107T2D
patientsand3
T1D
patients
NM
Glucose
monitoring,drug
dosage
andtiming
adjustment,andpatient
educationledto
decrease
intheoccurrence
ofserious
acutecomplications
ofdiabetes
during
Ram
adan
amongmostof
the
participants.Ingeneral,a
significant
improvem
entwas
foun
din
themeanblood
glucoseduring
Ram
adan
(8.67±
1.92
mmol/l)
comparedto
theestimated
averageglucose
(12.47
±3.94
mmol/l)
before
Ram
adan
(p\
0.000)
(effectsize,d
=1.23)
Diabetes Ther (2017) 8:227–249 235
Table3
continued
References
Cou
ntry
Metho
dsSampling
Participants
Respo
nse
rate
Results/outcomes
Ahm
edani
etal.
[25]
Pakistan
Prospectivestudyto
exam
inethe
implem
entation
outcom
esof
Ram
adan-specific
diabetes
managem
ent
recommendationsby
HCPs
inpatientswithdiabetes.Itwas
cond
uctedin
twostages;first
was
pre-Ram
adan
recruitm
ent
interview(visitA)in
which
individualized
coun
selling
and
educationalmaterialwere
provided
toeach
patient.
Second
stageisa
post-Ram
adan
follow-up
interview(visitB)of
thesame
patients.P
re-Ram
adan
Purposivesamplingfrom
nine
diabetes
specialistcentersin
four
provincesof
Pakistan
682patientswithdiabetes—
655T2D
patientsand27
T1D
patients
NM
Alterationsof
drug
dosage
and
timingwereun
dertaken
byabout91%
patientswith
T2D
and80%
patientswith
T1D
during
Ram
adan.N
ohospitalizations
were
required
becauseof
symptom
atichypoglycem
iaor
hyperglycemiaandno
diabeticketoacidosis,
hyperglycemic,and
hyperosm
olar
states
were
experiencedduring
Ram
adan.T
hestudy
highlighted
theacceptability
ofHCPs’recom
mendations
bypatientswithT2D
fasting
during
Ram
adan/aswellas
thebenefitsof
advice
provided
topatients
236 Diabetes Ther (2017) 8:227–249
Table3
continued
References
Cou
ntry
Metho
dsSampling
Participants
Respo
nse
rate
Results/outcomes
Ahm
edani
andAlvi
[40]
SevenCountries
(i.e.,Pakistan,
Bangladesh,
Afghanistan,
SaudiArabia,
Oman,E
gypt,
andSriLanka)
Observationalstudyof
the
characteristicsof
fasting
patients,trend
sof
Ram
adan-specific
diabetes
education,
and
implem
entation
ofdiabetes
managem
ent
recommendationsin
patients
withdiabetes
during
Ram
adan.T
hisstudywas
undertaken
mainlyby
general
practitioners,diabetologists,
andinternistsusing
standardized
questionnaire-based,
face-to-face
interviews
cond
uctedon
one-to-one
basis
Convenience
samplingafter
theendof
Ram
adan
2014
(August–Decem
ber).T
heincluded
participantswere
patientswithdiabetes
who
fasted
forat
least10
days
during
Ram
adan
of2014
6610
patientswithdiabetes—
6350
T2D
patientsand260
T1D
patients
NM
BeforeRam
adan,
approxim
ately48%
ofparticipantsreceived
Ram
adan-specific
diabetes
educationandnearly66%
patientswererecommended
toaltertheirmedications
timinganddosage,w
hile
about70%
received
dietary
advice.R
eceiving
Ram
adan-specific
diabetes
educationhelped
participantsto
follow
Ram
adan-specific
diabetes
managem
ent
recommendationsduring
Ram
adan
better
than
those
who
didnotreceivesuch
education
Diabetes Ther (2017) 8:227–249 237
Table3
continued
References
Cou
ntry
Metho
dsSampling
Participants
Respo
nse
rate
Results/outcomes
Lee
etal.
[37]
Malaysia
Apilotrand
omized
controlled
studyto
evaluate
the
short-term
benefitsof
atelemonitoring-supplemented
focuseddiabeticeducation
comparedwitheducation
alonein
participantswith
T2D
who
werefastingduring
Ram
adan
Random
selectionfrom
five
prim
aryhealth
care
provider
practicesto
telemonitoring
group(TG)or
ausualcare
group(U
C)
37T2D
patients:in
the
tele-m
onitoringgroup
(n=
18)who
received
goal-setting
andpersonalized
feedback
and19
T2D
patientsreceiving
Ram
adan-focused
pre-educationonly,i.e.,usual
care
NM
The
TG
experiencedfewer
hypoglycem
iasymptom
scomparedto
theUC
during
thestudyperiod
(88vs.1
57episodes),(O
R0.1273;95%
CI0.0267–0
.6059,
p[0.01)(effect
size
=-1.14*).H
owever,
therewas
nosignificant
difference
observed
inglycem
iccontrolat
theend
ofstudybetweenthetwo
groups.T
elem
onitoring
might
beaconvenient
addition
toim
proveglucose
monitoringandreinforce
Ram
adan-focussed
education.
Educational
initiativesandmonitoring
areessentialfor
patientswith
diabetes
willingto
observe
Ram
adan
READ
Ram
adan
educationandaw
arenessin
diabetes,C
Scross-sectionalstudy,OSobservationalstudy,NM
notmentioned,O
Rodds
ratio,
CIconfi
denceinterval
Effectssizeswerebasedon
Cohen’sdvaluesandsomeeffectsizescalculations
arefordifferencesbetweenpre-andpost-m
easuresrather
forbetweencontroland
intervention
groups
*Thiseffect
size
valuewas
calculated
onthebasisof
Chinn
’sexplanation[50]
238 Diabetes Ther (2017) 8:227–249
Table4
Characteristics
ofincluded
needsanalysis(pre-in
tervention
)of
research
studies
Autho
rCou
ntry
Metho
dsSampling
Participants
Respo
nse
rate
Results/outcomes
Amin
and
Chewning
[13]
Alexand
ria,
Egypt
CS;
self-administeredcustom
developedsurvey.T
hissurvey
hadaknow
ledgesection
comprising3item
stesting
awarenessaround
clinical
managem
entof
diabetes
in
fastingpatientsandabehavior
sectionwithitem
sconstructed
usingthetheory
ofplanned
behavior
Random
samplingoutof
alistof
3309
commun
itypharmacies
inAlexand
ria
277 pharmacists
93%
16%
ofparticipatingpharmacists
couldnotanswer
anyquestion
correctly
intheknow
ledge
sectionandonly8.5%
answered
allthequestions
correctly.M
ostreported
being
willingto
attend
aworkshopto
learnabouttheadjustmentof
medicationregimensduring
Ram
adan
Amin
and
Chewning
[20]
Alexand
ria,
Egypt
CS;
analyzed
theresponsesfrom
theabovestudyto
explorethe
utility
oftheplannedbehavior
theory
modelin
predicting
the
behavior
ofpharmacists
towards
adjustingmedication
regimensforpatientsduring
Ram
adan
Random
samplingoutof
alistof
3309
commun
itypharmacies
inAlexand
ria
277 pharmacists
93%
Samplepharmacistsweremore
likelyto
change
simpler
aspects
ofpatientmedications
(e.g.,
dose
regimen
changes,rather
than
recommending
adifferent
classof
medications).In
this
sample,currentpractice
was
limited
tominim
al
intervention
delivery,which
is
perhapsreflectiveof
provider
confi
dence
Diabetes Ther (2017) 8:227–249 239
Table4
continued
Autho
rCou
ntry
Metho
dsSampling
Participants
Respo
nse
rate
Results/outcomes
Wilbur
etal.
[45]
Qatar
CSdescriptivestudyusinga
Web-based
custom
developed
questionnairethat
contains
item
sfocussed
onpharmacist
attitudestowards
appropriate
patientcare
andknow
ledge
aboutmedicationadjustments
forpatientswithdiabetes
who
wereun
dertakingtheRam
adan
fast.T
hiswas
completed
by
participants3monthspriorto
Ram
adan
2012
Convenience
sampleobtained
from
Qatar
UniversityCollege
ofPh
armacy—
internal
pharmacistdatabase
178 pharmacists
31%
Pharmacistsreported
frequent
encoun
terswithpatientswho
have
diabetesduring
Ram
adan.
Only7%
ofpharmacists
achieved
agood
scoreon
know
ledgequestions.In
a
specificcase
question
pertaining
toantidiabetic
medicationadjustment,only
43%
ofsamplepharmacists
provided
thecorrectresponse.
Severalbarrierswereidentified
buttherewas
anoveralldesire
toassumegreaterrolesin
assistingpatientswithdiabetes
fastingduring
Ram
adan
240 Diabetes Ther (2017) 8:227–249
Table4
continued
Autho
rCou
ntry
Metho
dsSampling
Participants
Respo
nse
rate
Results/outcomes
Almansour
etal.[32]
Australia,
Sydn
ey
CS;
analyzed
pharmacists’
perspectives
regardingtheir
rolein
care
ofpatientswith
T2D
who
choose
tofast
during
Ram
adan
Convenience
sampleobtained
from
areasof
ethn
icdiversity
inSydn
ey
21
pharmacists
75%
Mostparticipantsencoun
tered
fastingpatientsandwere
willingto
engage
indiabetes
care
services.H
owever,
them
aticanalyses
indicated
reactive
coun
selling,lackof
perceivedneed
forcoun
selling
patientsor
delegation
of
patientcare(tophysicians)in
a
fewinstancesas
wellas
organizationalissues
asa
practice
barrier.Authors
concludedthat
professional
awareness/training
ofthe
impact
ofreligious
practices
such
asRam
adan
fastingis
essentialandhealth
care
servicesshould
bedevelopedto
help
thesepatientsto
practice
theirreligious
practices
includingRam
adan
fast
without
affectingtheirhealth
Diabetes Ther (2017) 8:227–249 241
Table4
continued
Autho
rCou
ntry
Metho
dsSampling
Participants
Respo
nse
rate
Results/outcomes
Gaboritet
al.
[42]
Marseilles,
France
CSwascond
ucted3month
prior
toRam
adan;study1with
patientswas
cond
uctedvia
face-to-face
interviewswiththe
aim
ofexploringattitudesof
patientsandstudy2exam
ined
physicians’attitudesregarding
Ram
adan
fastinganddiabetes
control.In
study2,
the
physicians
filledoutthe
questionnaires
ontheirow
n
foramax.tim
eof
30min
each
Purposivesamplingof
patients
withdiabetes
andGPs
recruitedduring
four
rand
omlyselected
medical
training
sessions
thatwerepart
ofacontinuing
medical
educationprogramme
101 patients—
81T2D
patients
and20
T1D
patients.
101GPs
NM
77%
ofGPs
stated
they
hadnot
read
aboutdiabetes
control
during
Ram
adan
andonly15%
hadmanaged
someacute
diabeticissues
during
Ram
adan.A
lmost52%
of
patientscontinuedto
fast
during
Ram
adan
andonly
about64%
ofpatientshad
discussedfastinganddiabetes
managem
entduring
Ram
adan
withtheirGPs.G
Psadvised36
patientsto
notfast,b
ut19
of
thosepatientsfasted
inspiteof
theirGPs’recom
mendations.
Consequently,six
fasting
patientsexperienced
hypoglycem
iaas
they
persisted
taking
oralhypoglycem
ic
medications
orinsulin
at
middayeach
day.The
study
demonstratedthat
formore
cultu
rally
sensitivecare
for
thesepatientsandmore
medicaltraining
forphysicians
areneeded
CScross-sectionalstudy
242 Diabetes Ther (2017) 8:227–249
many instances. None of the included inter-ventions were large robust randomized controltrials (RCTs), some were pre–post studies andothers were parallel group quasi-experimentalstudies [23, 25, 34–40].
Intervention Specifics
Most interventions targeted patients with dia-betes who intended to or have the intention tofast during Ramadan. Interventions were mostlydelivered by HCPs such as GPs, dieticians, andlink workers and a few involved spiritual leadersto recruit or motivate patients to participate insuch interventions. Most intervention studiesstated focussing on patients’ education on mealplanning, physical activity, glucose monitoring,hypoglycemia, dosage, and the timing of med-ications. However, in most instances, the detailsof the educational intervention, e.g., the formatof delivery, props used to support the educa-tion, or the clinical guidelines which informedthe educational interventions, were notdetailed. A few studies reported the languageand the duration of the education sessions[34, 36, 39]. In multicenter studies, no qualityaudits were considered [36, 40]. Hence in theseinstances protocol fidelity is not known.
Key Outcomes Measured
Intervention assessment is best served by mea-suring a balanced set of outcomes that includeclinical measures, economic benefits as well asfunctional health status and well-being [41].Key clinical outcomes measured in the reviewedstudies included weight or BMI, HbA1c, andadverse events occurrence. However, humanis-tic outcomes (e.g., adherence, quality of life,satisfaction, health beliefs, awareness, behav-iors, and attitudes) were not considered to assessthe effects of the interventions. Therefore, thesestudies did not look into details of whetherparticipating patients learnt/benefited fromthese studies outside the bounds of clinicalimprovement. In most instances, the follow-upperiod was short and only one study looked intothe sustainability of the outcomes 12 monthsafter patients attended the education [39]. In
this study, i.e., the Ramadan Education andAwareness in Diabetes (READ) program, HbA1creduction was sustained in the interventiongroup (-0.13%, p = 0.07), while the meanHbA1c in the control group increased by 0.33%(p = 0.03) [39].
Effect sizes of the educational interventionson key outcomes, where calculable, rangedbetween -1.14 and 1.7.
Needs Analysis (Pre-intervention) Studies
Needs analysis research studies were conductedboth with GPs and pharmacists, and patients.None of these included active interventionstudies. Non-validated instruments, self-report-ing methods, sampling in one area, and limitedscope of questions on diabetes knowledge wereissues that restricted the generalizability of theresults. While most HCPs were willing to pro-vide health care services, clearly their knowl-edge of how such services will be provided wassuboptimal, and most were open to moretraining about their role in managing diabetesduring Ramadan. There was a wide variation inthe knowledge of participating HCPs (GPs andpharmacists) about managing diabetes forpatients with diabetes intending to fast duringRamadan. For example, the majority of theFrench GPs interviewed by Gaborit et al. lackedthe clinical awareness about medical manage-ment in T2D patients observing Ramadan andcultural awareness about the relevance of thefast [42].
DISCUSSION
This is the first literature review to focusspecifically on the health educational inter-ventions, and intentions of HCPs such as gen-eral practitioners (GPs) and pharmacists, toprovide clinical services to patients with dia-betes while fasting during Ramadan. The reviewrevealed a paucity of research in this area. Therewere only a few intervention studies locatedthrough the search, and the generalizability ofthese studies was limited. Power calculationswere not undertaken for most interventionstudies, making it difficult to extrapolate the
Diabetes Ther (2017) 8:227–249 243
significance of findings. Outcome measurescollected varied and humanistic outcomes wereoften not collected. A detailed description ofactual intervention or education was lacking,and protocol fidelity (e.g., checks to see ifintervention providers followed research pro-tocols) and assessment of patient adherence(checks to see if patients adhered to recom-mended interventions) to recommendationswere not measured in any of the reviewedstudies. The overall trend, however, indicatedthat education, counselling by HCPs, anddosage adjustment for oral hypoglycemics inthe pre-Ramadan period help decrease adverseevents and can thus improve the experience ofpatients choosing to fast for religious/spiritualreasons. Clearly, robust studies with attentionto trial design need to be conducted.
None of the included studies had a robustdesign, some were pre–post studies and otherswere parallel group quasi-experimental studies[23, 25, 34–40]. In studies where randomizedsampling was undertaken, the randomizationmethod, allocation concealment, or blindedoutcome collection are not mentioned. In termsof outcomes, the full gamut of clinical andhumanistic outcomes was not covered and cer-tainly economic analyses, e.g., the cost-effec-tiveness of the educational interventions, werealso not conducted. One reason for this ofcourse may have been the lack of validatedquestionnaires/tools to measure humanisticoutcomes such as participants’ knowledge, sat-isfaction, and quality of life with these inter-ventions. These studies used self-developedquestionnaires. Future intervention studies inthis area should consider adequately poweredrandomized controlled designs, with blindingof outcome measurements at least as well as asuite of outcomes (clinical, humanistic, andeconomic) measured using validated instru-ments or techniques.
In most of the intervention studies, HbA1cor blood glucose level and diabetes-relatedadverse events were improved in the interven-tion group. These are promising outcomes, eventhough study designs were not very robust, asmentioned earlier. The positive trends in thedata observed suggested that well-designedhealth care education models for Ramadan
observers with diabetes should be developed.However, a preceding step that may needresearch investment is the development andvalidation of measurement tools that can beused in this population, particularly for mea-suring humanistic outcomes.
As highlighted in the ‘‘Results’’ section,intervention/education details were not clearlydescribed, which prevents other researchersfrom using effective materials and having toreinvent the intervention. These details includethe period of how long the education took,method of delivery (e.g., power point slides,face to face), and whether clinical guidelineswere followed in constructing the educationalintervention. Key clinical details of interven-tions were missing. For example, smokingaffects enzymes inducers, and smokers who fastduring Ramadan may stop smoking suddenlyduring the fasting time, which might affect thedoses of some medications. However, none ofthe intervention studies discussed whether doseadjustment in relation to smoking cessationhad been advised to patients. This is an issueobserved by authors of other systematic reviews,e.g., Okumura et al. reported the same issue in areview of intervention trials focusing on coun-selling [43]. Future research needs to considerthese details to enable other researchers toimplement such research in other countries formore global benefits and universalstandardization.
Most of the interventions were delivered byphysicians and allied health professionals inclinics. In most communities around the world,pharmacists are knowledgeable HCPs, veryeasily accessible and commonly visited by manypeople every day. Therefore, pharmacists’ valu-able contribution to patient care can be betterutilized. Research has shown that communitypharmacists can help with diabetes manage-ment generally [29, 44]. Therefore, it is logicalthat community pharmacists can help peoplewith diabetes who are observing the fast ofRamadan by providing information and helpingto adjust medications. Pharmacists’ awarenessof and willingness to do so was evident to someextent in the needs analysis studies included inthis review [13, 20, 32, 42]. There were nostudies describing the effect of well-designed
244 Diabetes Ther (2017) 8:227–249
structured clinical interventions delivered bypharmacists to patients with diabetes fastingduring Ramadan.
The studies that were located in the literaturehad several limitations; however, put together,these needs analysis (pre-intervention), in thecase of those conducted with pharmacists’,highlighted that pharmacists have the ability toenact specific roles in adjustments of medica-tion regimens for patients observing fasts withconcomitant diabetes [13, 20, 32, 45]. Hence, itwould be ideal to upskill pharmacists so theycan adjust medication regimens for patients toensure that they take their medications safelyand appropriately before, during, and afterRamadan.
Patient education research often highlightsthe chasm between patient behaviors and pro-fessionals’ recommendations. Several culturalfactors may affect communication and coun-selling by health professionals and similar fac-tors may also influence patients’ knowledgeabout their condition/medications as well astheir help-seeking behaviors. Thus, several typesof interventions may be useful: enhancing cul-tural understanding of professionals about theimportance of the fast to patients in developedcountries, as well as clinical training aboutadjustment of medication regimens for patientswith diabetes opting to fast during Ramadan inboth developed and developing countries.Ultimately, patients themselves can be upskilledto self-manage medications through effectivepatient education and medication adjustmentskills. Very few studies in this review directlyaddressed both provider and patient attitudes.The work reported by Gaborit and colleagues[42] was the only study in the review whichevaluated attitudes of both patients and physi-cians regarding Ramadan fasting and diabetescontrol in Marseilles, France. As highlighted inTable 3, the authors reported that many GPslacked the cultural competency and medicalknowledge that are needed to appropriatelycounsel their patients with diabetes in regardsto medication management during Ramadan.This resulted in medically unjustified recom-mendations against fasting. Culturally insensi-tive recommendations were ineffective, in that,directing patients peremptorily not to fast did
not appear to deflect vulnerable patients fromstill undertaking the fast [42]. Generally,patients may choose to ignore HCP advice,especially if they feel the HCP is not culturallyattuned to their decisions [42, 46, 47]. In thecase of Ramadan fasting, where religious beliefsstrongly motivate patients to fast, HCPs(physicians and pharmacists) and religioussources, such as imams (Muslim religiouspriests), may need to collaborate as importantsources of knowledge about fasting and medi-cation use for patients. This is a research areawith clear gaps, and further research on bothpatient-focussed or health professional-focussedresearch is needed.
A few studies have been carried out in Aus-tralia regarding diabetes management in CALDpopulations (i.e., Maltese immigrants to Aus-tralia), but not specifically during fasting. Oneof these studies reported on interview data fromMaltese immigrants in Sydney, Australia. Thiswas a qualitative exploratory study and high-lighted how patients in this group have limiteddiabetes knowledge. Interestingly, this group ofpatients were interested to receive more dia-betes care and counselling from communitypharmacists as they are easily accessible [44]. Itwas concluded that CALD populations havedistinctive barriers to health care that might beunknown to HCPs or unrecognized clearly bypatients themselves. Some of these barrierscould be due to low health literacy or lack ofaccess to educational programs [44]. The effectof a community pharmacy diabetes servicemodel on the outcomes of general patients withT2D in Australia has been assessed. As a result ofthese significant outcomes, the Australian gov-ernment provided a clinical intervention fee forpharmacists to provide an abbreviated versionof this service in the Fifth Community Phar-macy Agreement [48]. Such programs could alsobe developed for niche population groups aswell, i.e., specifically for Muslim patients withdiabetes intending to fast in Ramadan. Also,future research may consider electronic onlineformats of resources for patient education andawareness such as smartphone apps (for iOS,iPhone, and Android) as digital tools are usedcommonly worldwide. Contextualized explora-tory research seeking patients’ perspectives of
Diabetes Ther (2017) 8:227–249 245
problems or cultural issues regarding diabetesself-control would need to be conducted priorto designing such pharmacy-based interventionprograms. Pharmacists’ perspectives aboutdealing with cultural concerns that could affectpatients’ health or clinical confidence in pro-viding specific interventions was investigated inAustralia for this group and the findings of suchwork could be beneficial in the planning phaseof such intervention programs [32].
There are a few limitations of this scopingreview. Meta-analysis could not be conductedbecause the reviewed studies had mixed meth-ods/protocols of the interventions. Similarly, asystematic review was not conducted as most ofthe included studies were not robustly designedclinical trials. Another limitation is that dia-betes was considered mostly to be studied withrelation to Ramadan fast, because of the possi-bility of hypoglycemia occurring while fasting.However, other health conditions such as ang-ina, ulcers, asthma, and chronic obstructivepulmonary disease (COPD) should be consid-ered in future studies as fasting may affecthealth and medication use in relation to otherconditions.
CONCLUSION
The results of this literature review revealednumerous gaps in the existing literature. ManyHCPs and patients lack the knowledge for themanagement and modification of medicationregimens for patients with diabetes who fastduring Ramadan. Addressing the knowledgedeficits and enhancing cultural competency arecritical for clinicians treating Muslim patientsliving with chronic illness and observing thefasting practices of their faith. Very few studies,however, have addressed health providers’ atti-tudes, knowledge, and advice with regards tofasting. In Australia, where thousands of Mus-lims observe the fast of Ramadan each year, thisresearch area is becoming increasinglyimportant.
Pharmacists have been the focus of researchin this area in other countries and have been
shown to be willing to provide specialized carefor fasting patients with diabetes and willing toupskill themselves in order to provide suchspecialized care. Hence, there is a need forresearch that helps to describe the extent towhich Australian pharmacists counsel theirpatients about fasting during Ramadan, theirwillingness to provide specialized care, andtheir level of current cultural and clinical skills.Similarly, research with Muslim Australianpatients observing Ramadan will help establishtheir Ramadan-based diabetes self-managementbehaviors, and their perceptions about, andwillingness for receiving specialized help fromclinicians, including pharmacists. This researchmight assist in the development of such pro-grams in Australia.
ACKNOWLEDGEMENTS
No funding or sponsorship was received for thisstudy or publication of this article. All namedauthors meet the International Committee ofMedical Journal Editors (ICMJE) criteria forauthorship for this manuscript, take responsi-bility for the integrity of the work as a whole,and have given final approval for the version tobe published.
Disclosures. H. A. Almansour, B. Chaar, andB. Saini have nothing to disclose.
Compliance with Ethics Guidelines. Thisarticle is based on published studies, and doesnot involve any new studies of human or ani-mal subjects performed by any of the authors.
Open Access. This article is distributedunder the terms of the Creative CommonsAttribution-NonCommercial 4.0 InternationalLicense (http://creativecommons.org/licenses/by-nc/4.0/), which permits any noncommercialuse, distribution, and reproduction in anymedium, provided you give appropriate creditto the original author(s) and the source, providea link to the Creative Commons license, andindicate if changes were made.
246 Diabetes Ther (2017) 8:227–249
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