DIABETES, APPETITE CONTROL, and SAUM By Professor Omar Hasan Kasule Sr. 1.0 INTRODUCTION This paper deals with two ends of the spectrum of diabetes: prevention and control. Prevention and control of some forms of diabetes mellitus can be achieved by control of dietary intake because dietary intake is an important risk factor. The benefit is however seen in the long run as the patient changes lifestyle. The benefit may not be obvious during or immediately after Ramadhan. The long-term benefits are because saum is effective training and strengthening human will-power to restrict dietary intake within desirable levels. In the short term, saum may actually make matters worse because people to eat more food of a wider variety when breaking saum than in other months of the year. The paper then discusses special problems that arise when diabetic patients want to undertake saum. 2.0 BASIC EPIDEMIOLOGY OF DIABETES MELLITUS 2.1 Definition Diabetes mellitus is defined with hyperglycemia as a central feature. Two main forms of diabetes may be defined: Insulin-dependent-diabetes mellitus (IDDM) and non-insulin-dependent diabetes mellitus (NIDDM). Insulin dependent diabetes (IDDM) is the most serious form. It is due to loss of islet cells of the pancreas. NIDDM is generally milder. Diabetic conditions may also be found associated with some forms of malnutrition, pancreatic disease, ingestion of some drugs and chemicals, and pregnancy (gestational diabetes mellitus). Impaired glucose tolerance (IGT) may be found in both the obese and non obese. 2.2 Complications The complications of diabetes are microvascular (retinopathy, nephropathy, and neuropathy) or macrovascular (atherosclerosis, myocardial infarction, angina pectoris, stroke, and aneurysms). 2.3 Incidence The incidence of diabetes in increasing and it is feared that it may become an epidemic in some places. The incidence of IDDM is lower than that of NIDDM. IDDM has a prevalence of 2% in the UK population. IDDM is 25% of all DM cases. Geographical variation is noticeable. The peak age for IDDM is 12 yr. NIDDM is 75% of all DM in UK. Most patients are over 40yr; 10% of the patients are above 70 yr. British Asians are affected more than Caucasians. 2.4 Risk Factors The risk factors of IDDM are both genetic and environmental with the former being very strong. Variation of incidence over time, by ethnicity, and among migrants suggest environmental factors. NIDDM also has both genetic and environmental factors with the latter being predominant. It is associated with lifestyle, physical inactivity, obesity, fat distribution, and poor nutrition. Diabetes mellitus is associated with a diet characterized by high fat and low fiber content. 2.5 Prevention Preventive possibilities for endocrine and metabolic disorders are limited. Screening for diabetes was touted as a preventive approach however interest in screening for diabetes has waned because many causes of minor glucose intolerance are not significant on follow-up. Prevention of NIDDM depends on lifestyle changes in diet, exercise, smoking, and alcohol intake. Control of blood sugar levels reduces both microvascular and macrovascular complications. The main benefit of saum in the prevention and control of diabetes is a long-term reduction in dietary intake to healthy levels. 3.0 APPETITE, SATIETY, and FASTING 3.1 Strong human appetite for food Humans have an appetite for food that is a very strong instinct. This appetite is so strong that prayer is delayed when food is presented. It is conceivable that a hungry person will not concentrate sufficiently in salat. The strong appetite is because food is needed for survival. Human appetite is under the control of the hunger center, the thirst center, and the limbic system. Anorectic drugs e.g. amphetamine suppress the appetite. Appetite stimulants increase the desire for food. 3.2 States of satiety, maraatib al ghadha Satiety can be described in three states: the necessary, dharurat; the needed, haajat; and the excess, fadhl. Dharurat is the minimum nutritional intake necessary to maintain health in the best status. It represents the balance between excessive and too little intake. Haajat is intake that is more than dharurat but which prevents the feeling of hunger. It is however recommended not to eat to full satisfaction, shaba’u. Fadhl is the excess intake beyond the need. 3.3 Physiological fasting A human can survive for periods without food. Usually nights are periods of fasting. In a very revealing hadith the Prophet taught that supper should not be abandoned even if it is one date. This is in view of the prolonged period of physiological fasting during sleep. Even during the day humans do not eat continuously. There are periods of fasting during the day between meals or during Ramadhan. Humans can ingest 100 times more food than their immediate caloric needs. This food, in the form of glycogen and fats, is stored for later use. However fasting cannot be prolonged beyond a certain period because of the critical need of the brain for glucose. At rest the brain consumes 66% of the circulating glucose and requires 100-150g of glucose per day. Unlike other tissues it can not utilize fatty acids. Lipid deposits and muscle protein can be mobilized when needed but for a limited duration. 3.4 Control of appetite by iman There is a difference in attitude to feeding behavior between the believer and non-believer . The etiquette of eating is determined by the underlying vision. The believer eats to get energy for ‘ibadat. The non-believer may eat for enjoyment or to get energy for evil. The Prophet described Muslims as a community who ideally eat only when hungry and who do not fill their bellies when they eat, nahnu qawmu la na akul hatta najuu’u wa idha akalna fala shabi’ina. There is blessing in the food of the believer; he gets satisfied easily. The non-believer has to eat more food to get satisfaction. The Prophet Muhammad (PBUH) in a very revealing hadith mentioned that a believer eats in one stomach whereas a non-believer eats in 7 bellies. This means that a believer is satisfied 3.5 Control of human appetite by saum Saum Ramadhan is one the major acts of obligatory physical ‘ibadat. Besides the benefit of fulfilling an act of ibadat, fasting cleanses the body, al siyam zakat al jism. It is also a protection, al siyaam junnat. Voluntary hunger in Ramadhan gives the rich practical experience of hunger that makes them understand and appreciate the suffering of the poor Both obligatory and nafilat fasting help in controlling excess intake. The fasting person takes and absorbs less food in a day that a non-fasting one. Fasting is also training in appetite control during the ensuing non-fasting period. This is achieved in 2 ways: breaking routines and empowering the human will. Fasting breaks the normal routines of life that revolve around meals. It creates a different psychological milieu that liberates the mind from the routines of life and gives it an opportunity to reflect on the bigger issues of the creator, the good and the bad. A fasting person is able to control the appetite for food and to withstand hunger for a whole day. This is an exercise in self-control and self-discipline that empowers the person. This empowerment can be transferred to other life activities. Fasting is a means of instilling sexual self-control, al saum li man khaafa al 'uzuubat. 4.0 FAILURE TO CONTROL APPETITE 4.1 Intake-output balance The human body can be visualized as a chemical factory with inputs of food and other essentials like oxygen and outputs such as energy and complex molecules. The body essentially converts chemical energy of the organic molecules in the food into various forms of energy needed by the body (mechanical, electrical, chemical etc). The amount of energy needed by an individual is affected by: surface area, age, sex, and level of physical activity. Most energy expenditure is for contracting and moving muscles. It is a tragedy of modern civilization that humans still take three meals a day like their ancestors when they live sedentary lifestyles with limited physical activity. Energy intake in excess of energy expenditure translates directly into obesity and disease. The Law of conservation of energy holds true for the human body. Thus any violation of the Law of Allah, sunnat al llaah, about conservation of energy results into misfortune. 4.2 Cerebral overrule of the satiety center Satiety is the desire to stop eating further because of feeling satisfaction. It is controlled by the hypothalamus. Eating causes a rise in body temperature that signals to the hypothalamus to activate the satiety mechanisms. The distension of the stomach during a meal also sends signals that activate satiety. High blood sugar and high lipid levels may also cause satiety. Emotional and psychological factors also control satiety. In normal circumstances these negative feedback mechanisms can keep food ingestion within physiologically acceptable levels. However human will is able to overrule normal physiological control mechanisms. The body may crave for more food but the will can overrule it. In the same way the will can cause stopping feeding even before satiety is reached. 4.3 Diseases of nutritional excess Obesity is excessive accumulation of fat in the body when more energy is ingested that is expended. Obesity is a social and medical disease that was condemned by the prophet. He considered it a sign of social degeneration. Most cases of obesity are due to excess food intake although emotional, genetic, and endocrine factors play a role. Obesity may also be familial with no genetic basis when children grow in a family with excessive nutritional intake and grow into overweight or obese adults. Regular food intake without any physical activity may also lead to obesity. Overeating may be stimulated by certain drugs. In some cultures obesity especially of women is considered a sign of beauty and special medications are taken to achieve it. Factors that encourage over eating include: abundance of food with a lot of leisure time leading to social eating as entertainment and stress that finds relief in food. Obese persons have a shorter life-expectancy. Obesity is associated with hypertension, atherosclerosis, and diabetes. Obesity is an increased burden for the heart and also the skeleton and joints. Behavioral problems may be due to feeling bad about one self and may progress to neuroses and psychoses. Besides its association with disease, obesity in its extreme forms interferes with performance of physical acts of ‘ibadat such as saum, salat, and hajj. Obesity is treated by reducing food intake under medical supervision 5.0 SAUM OF A DIABETIC PATIENT 5.1 Legal Dispensations on saum with physiological impairments The following are allowed to break the saum because of physiological weaknesses: the elderly, al shaikh, the pregnant woman, al hublah if fasting is a risk to the health of the fetus and not the mother, the breast-feeding woman or nursing woman, al murdhi' if fasting is a risk to the health of the baby; and breast-feeding woman or nursing woman, al murdhi if fasting is a risk to the health of the mother, and the menstruating woman, al haidhah. The very sick with chronic disease and the elderly do not fast but feed the poor instead.. Those with curable diseases fast the missed days when they recover. The saum of a sick person is valid but is makruh. Diabetics being a physiological decompensation is covered under the general legal exemptions from saum. However there are differences in the rulings depending on the type of disease. The rulings about saum differ between insulin dependent and non-insulin dependent diabetics. Insulin-dependent diabetics have to reduce their insulin dose because of reduced food intake during the day. In some cases this is not possible and they have to be exempted from fasting altogether especially if their diabetic control is brittle. Pregnant diabetics are exempted from fasting because diabetic control is more difficult in pregnant women making fasting doubly hazardous for both the mother and the fetus. Non-insulin diabetics can undertake saum under medical supervision. This will generally require changing times of medication, close monitoring of blood sugar levels, and being alert to any hyperglycemic or hypoglycemic crises. 5.2 Measures to prevent physiological harm: The prophet (PBUH) taught measures to ensure that fasting does not cause physiologic damage. Fasting continuously from day to day, wisaal, was forbidden. Early breakfast was recommended. Delaying suhuur was recommended. 5.3 Medical guidelines for saum: The aim should be maintaining normal body weight or actually reducing it if overweight. Over-eating at iftaar and suhuur should be avoided. Over-eating will cause indigestion. The diet should contain sufficient fiber to prevent constipation. Fiber and slowly digested foods with a long stomach transit times are preferred. Enough water should be taken at night both for preventing dehydration and preventing constipation. Adequate fluid and salt intake prevents lethargy in the afternoon caused by low blood pressure. Hunger is a cause of headache especially later in the day. Intake of adequate calcium, magnesium, and potassium will prevent muscle cramps. Hot places should be avoided. Attempts should be made to keep cool. Inadequate sleep is a cause of headaches. In non-diabetics hypoglycemia may be due to insulin overproduction on intake of refined sugar. In diabetics it may arise due to insulin injections with inadequate dietary intake. Peptic ulcers are aggravated by raised acid levels. Kidney stones may be due to low fluid intake. Joint pains may be due to excess solutes. 5.4 Medication in saum The general rule is that any substance that enters the body through any of its openings, manfadh, nullifies fasting. The openings are the two ends of the alimentary canal, the mouth and the anus as well as the vagina. All drugs that are applied externally on the skin do not nullify fating. Sub-cutaneous, intra-muscular, and intra-venous injections do not nullify fasting. However nourishing injections nullify the purpose of fasting. Drugs of whatever form taken orally, per anus, or per vagina nullify fasting. Venepuncture does not nullify saum. Sub-lingual pills are allowed. The medication schedule can be modified such that drugs are taken only during the night hours. 6.0 RECENT RESEARC H ON SAUM AND DIABETES 6.1 Studies on the effect of saum on diabetic control have given many contradictory results. This is due to lack of careful control for confounding factors and the general change in dietary habits that occurs in Ramadhan compared to other months of the year. We will here quote only 2 of such studies. 6.2 Azwany et al  studied the impact of Ramadan fasting on glycemic control in type 2 diabetes patients. Forty-three Muslim type 2 diabetic patients or oral medication , with no renal or liver disease participated in the study. A total of 52 patients had been recruited giving a drop-out rate of 17.3%. Fasting blood glucose (FBG) and serum fructosamine levels were determined at four consecutive visits (at four weeks and one week before Ramadan, in the fourth week of Ramadan and four weeks after Ramadan). They found no significanty change in mean FBG over time ( Figure 1, p=0.12). There was however an increase in fructosomine from the first to the fourth weeks (figure 2, p=0.001). The study showed poor diabetic control because the subjects were more hyperglycaemic in Ramadhan. They concluded that the poor control reflected lack of knowledge about adjusting diet and medication during Ramadhan. 6.3 Yousef et al undertook a study to study the effects of Ramadhan on various physiological parameters in normal and diabetic patients (NIDDM). The study group consisted of 53 diabetic patients (31 male and 22 female) and 56 (21 male 35 female) healthy volunteers as controls. The subjects were evaluated 1-2 weeks before commencement of fasting (visit 1), at the 4th week of Ramadan fasting (visit 2) and one month after the end of the Ramadan fast (visit 3). Results are shown in Tables 1 and 2. They found statistically significant weight reduction (P<.001) at the end of Ramadan fast in both groups which was not maintained one month after Ramadhan. Fasting blood sugar and HBA1C showed significant reduction (P<.001) among diabetics but not in control group. However serum cholesterol, triglyceride, and uric acid increased among healthy volunteers (control group) one month after Ramadan; no such changes were seen among diabetic group.