Diabetes Care During Hajj

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]. Population-based 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].

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. 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-oriented awareness and patient education are of paramount importance in this endeavour [8].

Currently, only 55% of Hajj pilgrims with DM receive educational counselling before Hajj, and only 22% are aware of the need for self-monitoring [9]. These statistics emphasise the need for guidelines for the diabetic management of Hajj pilgrims so that physicians looking after these patients are more aware of the possible risks [4, 9]. The purpose of this narrative review is to provide comprehensive strategies for the effective management of the patient with DM during the pre-Hajj, Hajj and post-Hajj periods so that their risk of developing complications associated with DM is minimised. Our objective is to provide recommendations for clinicians so that they can carefully assess their patients, discouraging those at risk from undertaking the pilgrimage and providing safety recommendations for those deemed fit to undertake the journey. This article is based on previously conducted studies and does not contain any studies with human participants or animals performed by any of the authors.

In the setting of the COVID-19 pandemic, religious gatherings at Mecca are potential exposure settings that could facilitate the spread of the disease to Hajjis [12]. This perception is supported by studies that identified the crowded conditions of the Hajj as hotspots for transmitting antibiotic-resistant infections and pulmonary infections, which emphasises that this setting could also serve as a hotspot for the spread of COVID-19 [12]. In previous outbreaks of severe acute respiratory syndrome (SARS) and Middle East respiratory syndrome (MERS), Hajj pilgrims were found to show poor compliance with preventive protocols because of their inclination to fulfill religious commitments [13, 14]. Patients with DM are at a greater risk of developing a severe manifestation of COVID-19, with a resultant higher risk of mortality due to respiratory complications [7, 12]. Although the Hajj borders were open from 2 August 2020, keeping in mind the religious sentiments of a larger group, patients with DM must completely avoid Hajj gatherings until the spread of COVID-19 is contained in their home country as well as in Saudi Arabia [13, 14]. Post-COVID-19, safe international travel can be encouraged, but even then the need for social distancing and hygiene maintenance must be stressed [13, 14]. Elderly patients must take additional precautions, and those with uncontrolled blood glucose levels or an elevated risk of cardiovascular complications must not be allowed to travel unless the situation is regarded to be completely safe from the pandemic and diabetic points of view [15, 16]. In addition to COVID-19, infections due to Salmonella, Campylobacter and enterohemorrhagic Escherichia coli can be encountered during Hajj due to the lack of hygiene in overcrowded mosques and camps [9]. The risk of contracting any of these infections must be taken into careful consideration in the post-COVID period, especially among older pilgrims [13]. Upper respiratory tract infections are the most commonly encountered infections in this age group and are associated with an increased risk of hyperglycaemic complications [6]. A cohort study of elderly patients at Arafat hospital found that 39.4% of patients had pneumonia and 14.4% showed exacerbation of asthma and chronic obstructive pulmonary disease (COPD); among these patients, 59% required secondary and tertiary care facilities for the management of these complications [17]. The conclusion to be drawn, therefore, is that all necessary vaccinations and evaluations must be completed before the Hajj journey (Tables 1, 2).

Hyperglycaemia is a common manifestation among Hajj pilgrims, primarily due to a lack of/poor compliance to insulin administration prior to meals pertaining to irregular meal times [4, 18]. In a recent cross-sectional study, 27.4% of Hajjs had a high blood glucose level at the time of Hajj [19]. Patients with T2DM have a higher risk of acute complications than those with type 1 DM (T1DM) [19]. Such high rates of complications can also be due to over-indulgence of high-calorie foods, such as dates and fried food items during Hajj [4].

Current recommendations are that patients with DM strictly avoid the Hajj, both from national and international locations [13]. Post-pandemic, patients with poor glycaemic control, history of hypoglycaemia and/or presence of comorbid conditions must not go on the Hajj (Fig. 1).

Due to increased physical activity and non-compliance with the timing of meals during Hajj, all patients with DM are at a high risk of hypoglycaemia [21]. In a recent survey, approximately 37% of diabetic patients on Hajj were identified as hypoglycaemic; another 14.9 and 12.5% were reported with symptoms of hypoglycaemia in the form of fatigue and headache, respectively [19]. Such patients often tend to neglect medical care during hypoglycaemic events as they correlate it with general tiredness or drowsiness due to Hajj activities [22]. In terms of dose adjustment, it should be noted that for patients on insulin treatment, insulin in Saudi Arabia typically is provided at a concentration of 100 U/mL, which is different from the standard concentration of 40 U/mL available in most countries [23]. Consequently, if the dose is not adjusted accordingly, overdosing can be a risk [23]. High temperatures (range 37 to 45 °C) during Hajii also increase insulin absorption, resulting in hypoglycaemia, which must be accounted for during dose adjustment [24].

It has been been reported that 13.8% of Hajjis with DM have an underlying diabetic neuropathy, which which increases the risk for foot complications, such as wounds [26]. Diabetic foot ulcers are one of the most common reasons for Hajjis to seek medical attention, and treatment may consist of surgical management in critical cases [27]. Blisters are common in 31% of such pilgrims due to mechanical stress during walking [28], while another 25% of the patients have been reported to have erythema during the pilgrim rituals [29]. Patients with uncontrolled diabetes are at a higher risk of foot infections when compared with non-diabetics and patients with their diabetes under control [19‐27]. Patients with DM face developing severe complications due to compromised states of immunity, poor wound healing, and the presence of neuropathy and peripheral vascular disease [30].

There is also a significant risk of sustaining foot burns due to the high temperature of the ground in the summer months (approx.  60 °C), which later manifests into foot ulcers [27].

There is a high risk of renal diseases among diabetic patients performing the rituals of Hajj due to high levels of dehydration during the summer months, which affects renal function [27]. Hajjis tend to avoid drinking adequate amounts of fluid due to fear of polyuria during travel. Cardiovascular disease has been found to be most common cause of admission to intensive care units during Hajj [32]. Cardiovascular diseases occur due to physical and emotional exertion during Hajj and are manifested as chest pain, shortness of breath and palpitations [32].

Individuals with diabetes are at a greater risk of eye diseases because of the possibility of microvascular complications [36]. Among Hajj pilgrims with DM, 23.8% were found to have diabetic retinopathy [26]. This patient groups was at a greater risk of falls and injuries due to these visual disturbances [26].

The COVID-19 era must be regarded as the pre-Hajj period for patients with DM, during which time the need for regular self-monitoring can be emphasised through patient education. Similar to the pre-Ramadan health evaluation, an assessment must be made of the health status of a patient with DM with the aim to determine his/her fitness for the Hajj journey [22]. Capillary glucose monitoring is recommended over continuous blood glucose monitoring during Hajj because of the higher rate of patient compliance to the former [22].

Patients should undergo a complete clinical evaluation, including a thorough foot examination, renal and cardiovascular profile in their pre-Hajj medical assessment which should take place at least 2–3 months prior to Hajj [26]. Blood glucose levels of the patient, including fasting and post-prandial glucose levels, and glycated hemoglobin (HbA1c) levels must be closely monitored before their Hajj journey [9]. It is important to identify patients with existing microvascular/macrovascular complications and other comorbid conditions [27]. A cardiac evaluation with electrocardiogram should be performed in all patients with cardiovascular risk factors, and if any risk factors are found, the patient must be advised to avoid Hajj [32]. A two-dimensional echo and stress test should be performed when there is suspicion of coronary artery disease [32]. HbA1c levels of around 7% are indicative of a low risk category (Fig. 1), and these patients can be approved for the Hajj journey.

Other vaccines that must be taken include those for hepatitis A, B, and Bacillus Calmette-Guerin for the prevention of hepatitis and tuberculosis infections, which are common in Saudi Arabia [40]. Since no approved vaccination is currently available against the COVID-19, patients with DM should avoid making the Hajj journey until the pandemic has passed [14].

Patients with DM must be advised to increase their activity in a graded manner over a period of 6–8 weeks, especially walking, in order that they can cope with the physical rigors of Hajj and that their medication dosages can be better matched to their blood glucose levels. The following recommendations are made with respect to medication adjustment.

Patients with micro/macro vascular complications need additional evaluations, such as retinal examination, which must be appropriately scheduled with an ophthalmologist [37].