Diabetes care during Hajj and Umrah

Hajj is an important part of Islam for adult Muslims who are healthy and can afford it. It involves travelling to holy cities in Saudi Arabia like Mecca and Medina for about two to four weeks. During Hajj, pilgrims have to walk long distances and camp in tents in places like Mina, Arafat, and Muzdalifa. They also have to spend a lot of time standing and praying in Arafat. Because there are so many people, even simple tasks during Hajj can take a long time.

But Hajj can be tough on the body. Many older people who go on Hajj have health issues like diabetes, high blood pressure, or heart disease, which can get worse during the journey. The weather is usually really hot, around 37 to 45 degrees Celsius, and with so many people around, it can be crowded and uncomfortable. Plus, when you're in a new place with different weather, food, and habits, it can affect your health. During Hajj, people are focused on religious rituals, so they might not take care of themselves as well as they should. This, along with language barriers, can make it hard to get medical help if you need it. Some common health problems during Hajj include chest infections, diarrhoea, dehydration, heart issues, and some contagious diseases.

Diabetes and Hajj

Management of patients with diabetes whose care depends on a stable routine is affected significantly. The following health risks may be encountered in people with diabetes:

1. Low blood glucose
2. High blood glucose
3. Dehydration
4. Heat exhaustion and heat stroke
5. Chest infections, diarrhoea, middle east respiratory syndrome or COVID.
6. Foot infections and ulcers
7. Heart problems

Low blood glucose

Low blood glucose is always a risk during Hajj. It is because of unusually excessive physical activity, smaller meals, deviation from routine timing of meals, preference for performing prayer in the holy shrines (which may be quite away from the residence) may delay meal times. Excessive heat during the summer season may increase insulin absorption. Difference in insulin preparations between Saudi Arabia (available as 100-unit vials) and India (available as 40-unit vials) resulting in overdose if 100-unit insulin is given with 40-unit syringe.

Prevention and management:

1. Before starting a long walk, it is advisable to decrease the insulin dose by 20% and oral drug by half.
2. Before Ihram, check your blood glucose with a glucometer, if high (>250mgs/dl), give small dose of insulin (not more than 4 units of insulin R) to cover high blood glucose or take some bread if blood glucose is low (lower than 100 mgs/dl)
3. Before Tawaf and Saay, consume extra carbohydrates like bread.
4. Always take a mid morning snack like bread, or fruit like apple, pear, orange or strawberry, or nuts and seeds or low-fat yogurt or a bowl of soup to prevent sudden fall in blood glucose between breakfast and lunch.
5. In case of symptoms of low blood glucose (like exhaustion, headache, Palpitation, volatile behaviour, tremor or sweating, person should be treated with one of the following: honey (one tablespoon); dates (2-3); fruit juice (half a glass); sports drink (100 ml); glucose tablets; jelly sweets or 2-3 glucose biscuits with water, if possible, re check blood glucose after 15 minutes. If the person is unconscious and suspected to have low blood glucose (like an unconscious person drenched in sweat), honey should be rubbed on his gums or if possible, a glucagon injection given. After low blood glucose is corrected, a snack like a slice of a toast or sandwich or a bowl of cereal should be given.

High blood glucose

Lack of adequate insulin or intercurrent illness can increase blood glucose. In order to avoid this, continue to take insulin or diabetes medications, test blood glucose regularly, if it is >250(especially in type 1 diabetes), test for urine or blood ketones. If one feels sick, he/she should take some carbohydrate-containing drink as suggested above. If one still feels unwell, contact the healthcare team.

Dehydration

Take plenty of water (at least 8 glasses) during the day and carry water bottles with you all the time. Avoid caffeine or sugary drinks. If possible, carry an umbrella with you and use frequent water spray to keep one cool. In case of diarrhoea, consult the medical team for quick management of dehydration.

Foot infections and ulcers

In summer months, ground temperature may go above 50 to 60 degrees Celsius; temperature may be further high on hot marble. Walking barefoot in hot temperatures can cause burn injuries. In addition, cracks can develop in soles due to dry weather and hot temperature. Minor injuries to toes can also develop during Tawaf from stamping. Following measures will prevent foot problems:

1. Make sure that shoes, sandals you wear are of correct size, shoes should be “worn in '' before using extensively to prevent undue rubbing. Shoes should have a good ankle support and wide enough front part (to avoid extra pressure on feet and toes while walking). While walking in a mosque, it is permissible to wear leather socks, which will offer some protection. In order to avoid dryness, use moisturiser 3 to 4 times daily especially after Wudhu.

1. For travelling from one pilgrimage location to another, which can range from 5 to 15 km, the use of motorised vehicles or wheelchairs is recommended.  For activities within mosques, padded socks must be used in areas where shoes are prohibited; avoid walking barefoot wherever possible.
2.  For pilgrim activities that necessitate walking, light-weighted, softly padded shoes with padding at the heel and ball of the foot should be preferred. These shoes should be flexible enough to reduce the impact of the foot meeting the ground. Patients should be advised to dry their feet with cotton towels after performing wudu.
3. For safety and comfort, pilgrims are advised to use electric shavers rather than traditional razor blades. Additionally, wearing comfortable socks is recommended to reduce the risk of blisters and discomfort.
4. Daily foot inspection must be performed and dipping feet in hot water must be strictly avoided.

Kidney and heart disease

There is a high risk of kidney diseases among patients with diabetes performing the rituals of Hajj. This is due to high levels of dehydration during the summer months, which affects kidney function. Hajjis tend to avoid drinking adequate amounts of fluid due to fear of excessive urination during travel. Patients with diabetes and kidney disease should avoid dehydration and avoid self-medication.

A pre travel electrocardiogram is advisable and in case of symptoms like chest pain, palpitation, shortness of breath one should report to health facility as soon as possible.

SUMMARY & RECOMMENDATIONS

Before travel

1. Try to have a good control of diabetes mellitus even before commencement of journey.
2. Inform the manager about your disease and medications.
3. Complete your recommended vaccinations, including influenza and pneumococcal vaccines.
4.  Prepare adequate medications and place them in separate containers.
5. If possible, prepare a cool pack to store insulin.
6. Choose shoes, sandals and flip flops with appropriate shape and size.
7. Pack your medications in carry-on luggage rather than in checked baggage.

During travel

1. Always carry some sugar containing food to be used in case of low blood glucose (honey, jam, sweet biscuits etc).
2. Use as desired vegetables and two units of fresh fruits per day and avoid fruit juices.
3.  Drink at least eight glasses of water daily and carry enough water bottles with yourself.
4. If using insulin; before Ihram, check your blood glucose by glucometer. If needed, inject a small dose of insulin (if glucose is more than 250 mgs/dl) or some bread (if glucose is less than 70 mgs/dl).
5. Before and during long walking, decrease the dose of short and intermediate insulin about 20% and oral drug by 50%
6. Before Tawaf and Saay, consume some extra carbohydrate (bread is preferred).
7. Walk slowly during Tawaf and Saay, and try to protect your feet from damage by the ground tiles or other pilgrims. Avoid walking barefoot as much as possible, use moisturizer liberally.
8. In case of fever, diarrhoea, vomiting or any acute medical condition consult your medical team promptly instead of waiting in your residence.