Ziyad Alakkas1*, AlBaraa Yousef2 and Khaled A Alswat3
1Medical Resident, King Fiasal Hospital, Taif, Saudi Arabia
2Medical Student, Taif University, Saudi Arabia
3Assistant Professor of Medicine, Vice Dean of Graduate Studies and Scientific Research, Endocrinology and Internal Medicine Consultant, School of Medicine, Taif University, Saudi Arabia
Received: 27 April, 2015; Accepted: 22 May, 2015; Published: 22 May, 2015
Ziyad Alakkas MBBS, Medical Resident, King Fiasal Hospital, Taif, Saudi Arabia, Tel: +966566033434; Email:
Alakkas Z, Yousef A, Alswat KA (2015) The Association of Previous Hajj Performance on the Diabetes Preparation during the Hajj Season. Int J Clin Endocrinol Metab 1(1): 001-006.
© 2015 Alakkas Z, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Diabetes; Hajj; Readiness; Preparation
Methods: A cross-sectional study, collected from the Pilgrimages with diabetes during the Hajj season. Baseline characteristics were collected by a formal interview and the measurements were self-reported. The primary outcome was to evaluate the patients' Hajj readiness and the association of the previous Hajj performance on this outcome.
Results: Of the 262 patients with diabetes participated, 72.9% have type 2, mean age of 53.1 years; mean duration of diabetes is 9.23 years.
Compared between patients with diabetes participated who did Hajj for the 1st time to who did it more, 79 (30%) vs 183 (70%). Having enough medication 67.1% vs. 67.2% (p 0.63), extra-supply 20% vs. 20.8% (p 0.23), checking glucose during Hajj 16.5% vs. 20.8% (p 0.42), wearing medical wristband 5.1% vs. 6.0% (p 0.77), and having hypoglycemia rescue kit 20.3% vs. 18.3% (p 0.67), respectively.
Those who were seen by the Endocrinology/Family physicians were more likely to inform their physicians about the Hajj but only those seen by Endocrinologist were more likely to be offered a medical letter explaining their condition.
Conclusion: Except for carrying enough medications, pilgrimages with diabetes readiness parameters were far below 50% which indicates poor preparation for Hajj. No impact of previous Hajj performance on the study primary outcome.
The Hajj is the Fifth pillar of Islam, an annual Islamic pilgrimage to Makkah, Saudi Arabia and a mandatory religious duty for Muslims which must be carried out at least once in their lifetime by all Muslims who are physically and financially capable of undertaking the journey, and can support their family during their absence [11. Long, Matthew (2011) Islamic Beliefs, Practices, and Cultures. Marshall Cavendish Corporation. 86.].
Every year, millions of Muslims make a religious pilgrimage to Makkah on the eighth through thirteenth days of month 12th (Dhu-alhijah) of the Islamic calendar [22. Gabriel Said R (2012) The Emergence of Islam: Classical Traditions in Contemporary Perspective. Fortress Press. 33.]. The gathering during Hajj is considered one of the largest annual gatherings of people in the whole world over a short period of time. Because the Islamic calendar is roughly eleven days shorter than the Gregorian calendar, the Gregorian dates for Hajj varies from one year to another. Thus, each year in the Gregorian calendar, the pilgrimage starts eleven days (sometimes ten days) earlier than the preceding year which affects the season that the Hajj will be held in every few years [33. World Health Organization (WHO), Hajj related health problem 1999.].
During Hajj, pilgrimages perform a series of physical practice which considered moderate in intensity. Those includes person walks counter-clockwise seven times around the Ka'aba, also walks back and forth between the hills of Al-Safa and Al-Marwah, goes to the plains of Mount Arafat and Muzdalifa, and performs a lot of walking between sites. The practices are themselves simple, but the amount of physical activity, the hot climate, and the crowds make the Hajj a rigorous exercise in faith.
Diabetes mellitus is a metabolic disorder characterized by chronic hyperglycemia with disturbances of protein, carbohydrate and fat metabolism resulting from defects in the action, secretion of insulin or both. The effects of diabetes mellitus include long–term damage and serious long-term complications include cardiovascular disease, stroke, kidney failure, foot ulcers and damage to the eyes which may impact their abilities to perform physical activity [33. World Health Organization (WHO), Hajj related health problem 1999.]. Symptoms include increased in thirst, hunger and frequent urination which with the increase in the physical activity may predispose patients to numbers of acute complications like hypoglycemia and dehydration [44. Diabetes Fact Sheet. WHO. Jan. 2015].
As of 2014, an estimated 387 million people have diabetes worldwide [55. The International Diabetes Federation (IDF) facts sheet. 2014]. 80% of diagnosed cases were in low& middle-income countries, which is equal to 8.3% of the adult population [66. The top 10 causes of death. World Health Organization. Oct 2013. ]. In the years 2012-14, diabetes is estimated to have resulted in 1.5-4.9 million deaths per year which at least double the risk of death [66. The top 10 causes of death. World Health Organization. Oct 2013. ]. The number of people with diabetes is expected to rise to 592 million by 2035 [55. The International Diabetes Federation (IDF) facts sheet. 2014]. The global economic cost of diabetes in 2014 was estimated to be $612 billion USD [77. International Diabetes Federation: IDF Diabetes Atlas. 6th edition. 2013 ]. According to the most recent IDF publication, at least 3 out of the top 10 countries with the highest prevalence rates of diabetes in the world are within the Arabic Gulf region (Saudi Arabia 24%, Qatar 23%, and Kuwait 23%) [77. International Diabetes Federation: IDF Diabetes Atlas. 6th edition. 2013 ].
With increase physical activity during Hajj which may precipitate patients for the acute complications. Many diabetic pilgrimages are admitted to hospitals from diabetic complications during Hajj trip with heart, kidney diseases or diabetic foot [88. Al-Ghamdi SM, Akbar HO, Qari YA, Fathaldin OA, Al-Rashed RS (2003) Pattern of admission to hospitals during muslim pilgrimage (Hajj) Saudi Med J 24: 1073-1076. ,99. Alzahrani AG, Choudhry AJ, Al Mazroa MA, Turkistani AH, Nouman GS, et al. (2012) Pattern of diseases among visitors to Mina health centers during the Hajj season, 1429 H (2008 G). J Infect Public Health. 5: 22-34.].
The diabetes education is an important aspect to understand the disease, how it affected by the lifestyle, how to properly manage the diabetes emergency condition like hypoglycemia, and to how to minimize the risk of such complications [1010. Alsafadi H, Goodwin W, Syed A (2011) Diabetes care during Hajj. Clin Med 11: 218-221.].
The primary study aim was to assess the patient readiness to Hajj trip and its association with type of care, advice received and history of multiple hajj performance.
Population and design
A cross-sectional study was conducted between Oct 4th- 6th, 2014. We conveniently selected pilgrimages with diabetes aged 18 years and older from different pilgrimage campaigns in the holy city of Makkah were offered to participate in the study and the information were filled and collected by the team members. The body weight (BMI), height, fasting glucose level, random glucose level, and recent HbA1c were subjectively self-reported.
The survey included socioeconomic data, number of previous Hajj trip, pre and during Hajj diabetes related education, and self-reported chronic conditions. The chronic conditions we inquired about were hypertension, hyperlipidemia, stroke, peripheral vascular disease, snoring/witness apnea, chronic renal disease, and diabetic foot ulcer. To assess diagnosed diabetes respondents were asked 4 separate questions: “Have you ever been told by a physician, nurse or other health professional that you have diabetes mellitus; 2) type of diabetes; 3) duration of Diabetes; 4) management of diabetes (oral, insulin, or both).
Pilgrimages readiness and preparation for the Hajj was assessed by the following parameters; the last visit to the diabetes clinic within the last 3 months prior to the Hajj; informing patient physician about the hajj plan, the specialty of the caring physician; any change or adjustment made to the patient medications by the provider; did patient physician performed ECG as part of pre-Hajj clinic evaluation before the trip; regular glucose checking during the Hajj trip; carrying enough supply of medications during the Hajj, wearing wristband, carrying cool wallets for insulin, letter from the caring physician detailing the medical problem and the medications, hand luggage rescue carbohydrate, protective shoes, and diabetes emergency kit.
We analyzed the demographic characteristics and the preparation for the Hajj categories between whom done the hajj for the 1st time and those who performed it before by using the SPSS program using one-sample T-test. The primary goal of this study is to survey and evaluate the diabetic's clinical characteristics and its relation to patient readiness to Hajj trip based on their previous Hajj performance. We also assessed the relation between the different health care provider specialty and the Hajj readiness parameters.
Total of 262 pilgrimages with diabetes participated 237 (90.5%) were male and 25 (9.5%) were female, 65.3% were Saudi and 34.7% Non-Saudi, 95.4% were Middle Eastern ethnicity, 3.4% were African, and 1.15 were Asian. 55.7% with a degree of high school or higher and 21% with an intermediate school degree or less (Table 1). (Please refer to 2nd paragraph in the discussion).
The mean age was 53.06 years old (SD 11.7 years), mean BMI 29.65, 72.9% have type 2 diabetes (T2D) and 27.1% were type 1 diabetes (T1D), with a mean duration of diabetes is 9.23 years, and among them 40% were also hypertensive, 46% with hyperlipidmia and 5.7% with chronic kidney disease. The mean number of previous Hajj trips was 4.16 times.
Of the interviewed pilgrimages with diabetes, 180 (68%) were following up with General Practitioner, 65 (25%) with an endocrinologist and 17 (7%) with a family physician. The mean time to the last follow up visit was 74 days before the hajj season, 68% had their last follow up visit within 3 months but only 36% of them informed their doctors about their intention to do Hajj.
Compared between participated pilgrimages with diabetes who did Hajj for the 1st time to who did it more, 79 (30%) vs 183 (70%). mean age is 51.7 yr vs. 53.7(p .21), mean BMI 30.8 vs. 29.2 (p.07), mean duration of diabetes 9.5 yrs vs. 9.1 yrs (p.68), mean time of the last clinic visit was 65.4 days vs. 77 days (p.16), 35.4% informed their physician about their trip vs. 36.1% (p 0.92), 10.1% vs. 6.6% (p 0.32) have a medical letter describes their case from their providers, 32.9% vs. 24.04% ( p 0.12) changed their medications prior to the trip, and 46.8% vs. 46.4% ( p0.9) did ECG prior to their Hajj (Table 2).
1st time Hajj performers vs. previous performers, 67.1% vs. 67.2% (p 0.63) carries enough medications supply , 20% vs. 20.8% (p 0.23) carries extra-supply, 16.5% vs. 20.8% (p 0.42) reports checking their glucose during the Hajj, 5.1% vs. 6.0% (p 0.77) wear medical wristband, 20.3% vs. 18.3% (p 0.67) carries hypoglycemia emergency rescue kit, 39.2% vs. 38.8% (p 0.95) carries carb for rescue hypoglycemia, and 50.6% vs. 53.6% (p 0.67) wear protective shoes. Of the total of 89 patients were on insulin, 61.5% vs. 47,6% (p 0.45) carries insulin wallet (Figure 1).
Most of the caring providers were General Practitioner (GP) (Table 3). Comparing the patients characteristics according the specialties of the provider which are GP, Family physicians, and Endocrinologist; last visit to the clinic within last 90 days 58% vs. 82% vs. 92% (p <0.05), last visit was 84 vs. 66 vs. 50 days (p 0.12), 23% vs. 71% vs. 63% of the patients informed their physicians about the hajj trip (p<0.05). Checking glucose regularly before the trip was 39% vs. 77% vs. 60 % (p 0.002), having medical letter describes their case from their providers 6% vs. 6% vs. 29% (p 0.04), check glucose regularly during the trip was 16% vs. 24% vs. 28% (p 0.04) (Figure 2).
36% of the sample informed their physicians about the Hajj Trip (Table 4). Compare to those who didn't informed their provider about their Hajj plan, 96% of those who informed their physician had their last clinic visit within the last 90 days (p <0.05), more likely to wear identifying wristband during the Hajj trip 12% (p 0.002) , more likely to carries carbohydrate hand luggage 53% (p <0.05) (Figure 3).
Hajj is one of the five pillars of Islam which involves increase in the physical activities which may precipitate individuals with chronic medical conditions for acute complications. Pilgrimages with diabetes are at increased risk of such acute complications like dehydration and hypoglycemia. Proper patient's education and making sure patients is ready for the trip is an essential component for a safe Hajj trip.
Up to our literature review and to the best of knowledge, there is no published study that has assessed the patients with diabetes readiness for such trip. In this study we showed that the overall readiness's for pilgrimages with diabetes were poor according to the studied parameters. Those outcomes weren't affected by demographic distribution, race, gender education level or the number of previous Hajj performance.
When we stratified patients according to the provider specialty, although there was no significant difference in their baseline characteristics; the diabetics whom seen by the Family physicians or the Endocrinologist were significantly more likely to visit the clinic within 3 months from the Hajj trip, informing their provider about the Hajj plan, and more likely to check their glucose regularly. Only those seen by Endocrinologist were offered a medical letter explaining their medical condition and their medications.
Around half of the patients who were on insulin carries insulin wallet which is disappointing since the weather during the Hajj as well as the Hajj living situation (most of them stay in tents during the Hajj days) increases the chance of insulin denaturing which may increase the risk of dehydration and hyperglycemia.
Those who visited the provider clinic within the last 3 months from the Hajj season were more likely to inform their physicians about the Hajj trip and significantly more likely to wear medical wristband and more likely to carry carbohydrate for hypoglycemia treatment.
The observed poor readiness parameters despite the multiple previous Hajj performance may be related to lack of proper patient-physician communication as well as seeing general practitioner who may not aware about the recent related recommendations. Increase awareness among the providers and among the public about the importance of the clinic visit and informing the provider about the Hajj plan will increase the chance of proper readiness for such trip.
Our study has strength and limitations. The strength includes the relatively original research question that bridges relatively lack of information. The limitations that are our study design which limits our ability to assess causality, self-reported data, predominantly Saudi male, most of whom multiple Hajj performers, and the small sample size which limits the generalizability potential of such study.
Our recommendation to pilgrimages with diabetes who want to perform Hajj trip includes; patients should inform the caring physician about the Hajj Trip, optimize medical treatment with your provider aiming for better control of blood glucose and blood pressure during Hajj, vaccination (Influenza and meningococcal vaccines), carry adequate medications and cool pack to store insulin, finally carry hypoglycemic rescue kit [1111. Mansour Aivash, Sepehr Haghighi (2012) Recommendations for patients with Diabetes Mellitus during Hajj pilgrimage J Res Med Sci 17: 988-989.]. Also, during Hajj Trip always wear Protective shoes, check glucose before any vigorous activity, drink a lot of water during the day (at least 8 glasses) [1212. Beshyah S, Sherif I (2008) Care for People with Diabetes during The Moslem Pilgrimage (Haj) An Overview. Libyan J Med 3: 39-41.] and Eating a balanced health food contain an adequate Carbs, Fat and Protein [1313. Franz MJ, Bantle JP, Beebe CA, Brunzell JD, Chiasson JL, et al. ( 2004) Nutrition principles and recommendations in diabetes. Diabetes Care 27: S36-46.].
Pilgrimages with diabetes in our study were older, overweight and have longstanding history of diabetes. Except for carrying enough medications, all other studied Hajj trip readiness parameters were far below 50% which indicates poor preparation for the Hajj trip. There was no impact of previous Hajj performance on the study primary outcome.
We thanks Waleed althobaiti, Abdulrahman Al-zahrani, Ahad Alhabsi, Ali Alkhathami, Osama Barakat, Abdullah alalyani, Ahmad alsufiny, Turki al-zidani, Yasser Alsini, Osama Alsulaymi, Abdullah Alturkistani, Mohammed alzahrani, yasser hadi, Ehsan Alsini; in their role in Data collection phase.
- Long, Matthew (2011) Islamic Beliefs, Practices, and Cultures. Marshall Cavendish Corporation. 86.
- Gabriel Said R (2012) The Emergence of Islam: Classical Traditions in Contemporary Perspective. Fortress Press. 33.
- World Health Organization (WHO), Hajj related health problem 1999.
- Diabetes Fact Sheet. WHO. Jan. 2015
- The International Diabetes Federation (IDF) facts sheet. 2014
- The top 10 causes of death. World Health Organization. Oct 2013.
- International Diabetes Federation: IDF Diabetes Atlas. 6th edition. 2013
- Al-Ghamdi SM, Akbar HO, Qari YA, Fathaldin OA, Al-Rashed RS (2003) Pattern of admission to hospitals during muslim pilgrimage (Hajj) Saudi Med J 24: 1073-1076.
- Alzahrani AG, Choudhry AJ, Al Mazroa MA, Turkistani AH, Nouman GS, et al. (2012) Pattern of diseases among visitors to Mina health centers during the Hajj season, 1429 H (2008 G). J Infect Public Health. 5: 22-34.
- Alsafadi H, Goodwin W, Syed A (2011) Diabetes care during Hajj. Clin Med 11: 218-221.
- Mansour Aivash, Sepehr Haghighi (2012) Recommendations for patients with Diabetes Mellitus during Hajj pilgrimage J Res Med Sci 17: 988-989.
- Beshyah S, Sherif I (2008) Care for People with Diabetes during The Moslem Pilgrimage (Haj) An Overview. Libyan J Med 3: 39-41.
- Franz MJ, Bantle JP, Beebe CA, Brunzell JD, Chiasson JL, et al. ( 2004) Nutrition principles and recommendations in diabetes. Diabetes Care 27: S36-46.