The annual Haj pilgrimage, a journey that lasts for five days, begins from Thursday this week. And, not just healthy adults, people with diabetes also undertake this journey, which has been described as an “arduous and physically challenging event”. Diabetics need special care to prevent the complications that may occur owing to their diabetic status. Awareness about these unique requirements can avert possible health hazards during the religious journey.

The health risks

A major challenge that people with diabetes face is maintaining optimal glycemic control. Those who take insulin or sulfonylureas to manage their blood glucose are particularly at risk. The irregular meal timings may wreak havoc with the insulin dose and schedule causing the blood glucose to either spike or fall. The most serious acute hyperglycemic complications are diabetic ketoacidosis (DKA) and the hyperosmolar hyperglycemic state (HHS). Overindulgence in high calorie foods such as fried foods may also cause the blood glucose to rise. Another consequence of irregular meals or inadequate insulin therapy is hypoglycemia, the risk of which may be compounded by the strenuous physical activity and the hot climate. Lack of knowledge about proper insulin storage may add to the risk. It is also important to know about the differences in insulin doses as ignorance about concentration per ml of insulin may lead to insulin overdose and consequent hypoglycemia. Insulin available in India and other places may differ. These diabetic emergencies require immediate intervention, else they may prove to be fatal.

There is a risk of it becoming a flashpoint for outbreaks of communicable diseases such as respiratory infections, including the Middle East respiratory syndrome coronavirus (MERS-CoV), food and water-borne illnesses and now Covid-19. The humongous crowds, shared lodgings and hot weather are ripe conditions for the infectious pathogens to propagate. Lack of personal and/or food hygiene enhances the risk of infection.

Foot injuries are prevalent because the pilgrimage entails walking for long distances. Blisters and erythema are common. Foot burns due to walking barefoot in hot weather can occur, progressing to foot ulcers and infected foot ulcers. Poorly-controlled diabetes is a risk factor for slow healing of wounds. The underlying diabetic neuropathy increases the risk for foot complications.

Since diabetes is often comorbid with heart disease, hypertension, CKD, a large percentage of the pilgrims may also have hypertension and/or other underlying health conditions along with diabetes, which can be asymptomatic. The physical and emotional stress of the pilgrimage may trigger acute cardiovascular events, congestive heart failure and hypertensive emergencies. Cardiovascular disease has emerged as the leading cause of death during Hajj.

Heat-related illnesses (heat exhaustion and heat stroke) are other health hazards. The heat and sweating may predispose to bacterial infections such as pyodermas, carbuncle and furuncles.

Pretravel preparation

A comprehensive health check-up coupled with biochemistry and patient education about potential health challenges will facilitate a safe pilgrimage for persons with diabetes. Those who plan to go for the Hajj should gradually increase their level of physical activity in a graded manner and under guidance to acclimatise themselves to the physical stress of walking during the pilgrimage.

Risk stratification is important to identify those who can undertake the journey and who should desist from traveling. Patients with uncontrolled diabetes, stage 3 or higher CKD and moderately severe hypertension should avoid the journey.

• Patients should be educated about Hajj-specific self-management of blood glucose and self-monitoring.
• Patients should be counselled about carrying emergency snacks (as permitted) and a document summarizing their medical history and proper storage of their medications.
• All required vaccinations, including Covid-19 (primary vaccination and precaution dose) should be completed.
• A pretravel ECG will help to detect underlying heart disease.
• A review of the prescribed medicines is warranted. A decrease in the dose of insulin and sulfonylureas may be recommended depending on the glycemic status of the patient. Tight control of blood glucose is not recommended during Hajj considering hyperglycemia as the lesser of the two evils viz. hyperglycemia and hypoglycemia.
• The pilgrims must be advised to carry with them adequate supplies of medications along with glucometer/self-monitoring devices (dipstick for ketone). And, also keep themselves well-hydrated.
• Foot hygiene is imperative. A good quality non-fragrant moisturizer should be used everyday to prevent cracks and fissures during walking. Daily food inspection must be done. Avoid walking barefoot on hot surfaces to prevent foot burns. For the same reason, feet should not be dipped in hot water. Light-weight soft and well-fitting shoes must be used. Padded socks should be worn in areas where shoes are forbidden.

Patients with diabetes are at risk of severe Covid-19. Hence, use of face masks and adherence to covid-appropriate behavior is a must.

Care of diabetes does not end with the pilgrimage. A post-Haj follow up is required and details about the course of the disease during the journey must be elicited. Re-adjustment of anti-diabetic medication as per the current blood glucose levels may be necessary.

Suggested Reading

1. Safwaan Adam, et al. Diabetes care for the Hajj. Eur J Intern Med. 2016 Mar;28:e7-8.
2. Sarosh A Khan, et al. Hypoglycemia in diabetics during Hajj. Saudi Med J 2002;23(12):1548.
3. Shehla Shaikh, et al. Diabetes Care During Hajj. Diabetes Ther. 2020 Dec;11(12):2829-2844. doi: 10.1007/s13300-020-00944-5.
4. Metab Algeffari. Diabetes and Hajj pilgrims: A Narrative review of literature. J Pak Med Assoc. 2019 Jun;69(6):879-884.