AMMAN, Jordan (AP) — For years, diabetic Shawkat al-Khalili ignored his doctor's orders not to fast during the holy month of Ramadan when most of the world's 1.6 billion Muslims abstain from food and water from sunrise to sunset.
Islam exempts the sick from fasting, but the 70-year-old al-Khalili said he couldn't bring himself to violate one of the five pillars of his religion, even after he lost a toe to diabetes.
Like the retired teacher in Amman, tens of millions of diabetic Muslims struggle each year with such stressful choices. Increasingly, physicians team up with preachers or look for new methods to educate and protect the faithful.
The stakes are rising, particularly in the Arab world, where diabetes is spreading rapidly because of growing obesity caused by a more sedentary lifestyle and easy availability of processed food.
The Middle East and North Africa, which are overwhelmingly Muslim, have the world's highest comparative prevalence of diabetes, according to the International Diabetes Federation. In 2014, some 38 million people in the region, or one in 10, were diabetics, a figure expected to double in a generation, the federation says. Another 18 million suspected sufferers have yet to be diagnosed.
In recent years, the fast has also become more challenging for diabetics and their physicians as Ramadan — a lunar month that moves through the seasons — now takes place in summer. In many parts of the Mideast, temperatures exceed 40 degrees Celsius (100 degrees Fahrenheit) and daylight lasts for 15 hours, increasing risks of low blood sugar and dehydration.
This year, Ramadan is to begin on Wednesday or Thursday, depending on the sighting of the crescent moon.
Despite the hardships, compliance with Ramadan rules is widespread. Those who don't fast usually eat and drink in seclusion out of respect. Ramadan is also a time of increased religious observance and socializing, with families sharing rich meals after sunset, followed by gatherings with friends or neighbors.
In this climate, devout Muslims with diabetes say it's very difficult to be the odd one out.
Al-Khalili said he was diagnosed with Type II diabetes 30 years ago and kept fasting. About 10 years ago, doctors told him he had to stop, but he wouldn't.
He kept ignoring his doctors even after his left toe was amputated four years ago. Finally, two years ago, he stopped fasting.
"I don't feel good because I'm not practicing a major pillar of Islam, but it's ... necessary for protecting my health and stop the deterioration," al-Khalili said during his pre-Ramadan checkup Sunday at Jordan's National Center for Diabetes, Endocrinology and Genetics. "I hope God will forgive me."
Dr. Nahla Khawaja, an endocrinologist, said it's the busiest time of the year at the center, with most patients asking for Ramadan guidance.
Under the center's rules, Type 1 diabetics — whose bodies don't make the blood-sugar regulating hormone insulin — should not fast. For many Type 2 diabetics, or those whose bodies don't make enough insulin, the no-fasting recommendation also applies.
This includes those with uncontrolled blood sugar levels, those suffering from frequent sharp drops in blood sugar and those with advanced complications, such as damage to eyes, kidneys or limbs, Khawaja said.
Those who ignore the advice can face a range of risks, from fainting and dizziness to a diabetic coma and stroke.
"It's a great struggle" to persuade patients to not fast, particularly the elderly who often become more devout with age, Khawaja said.
However, other Type 2 diabetics can fast safely under supervision, and some, including recently diagnosed obese patients, might actually benefit from fasting, said Egypt-based Dr. Adel el-Sayed, the MENA chair of the International Diabetes Federation. He said diabetics who insist on fasting need to have their treatment adjusted and blood sugar closely monitored to mitigate the risks.
Sawsan Abu Amireh, a patient at the Jordanian center and a Type 1 diabetic, said she stopped fasting in 2010 on her doctor's orders. "I'm very upset when I see my children fasting and I'm not fasting," said the 46-year-old. "I even take my medication out of sight of my children (during Ramadan)."
In some areas outside the Middle East, physicians have teamed up with imams to get the message across.
A leading diabetes charity, Diabetes UK, publishes information on fasting and Ramadan on its website, including talking points for Muslim preachers.
Newham University Hospital, in a heavily Muslim neighborhood of London, offers pre-Ramadan programs where diabetics can hear the religious and medical views on safe fasting. They also are counseled to avoid the common excesses of Ramadan, such as consuming large amounts of fatty and sweet foods in the evening.
The hospital's imam, Yunus Dudhwala, said his job is to make sure doctors and nurses understand the religious importance of the fast.
"If medics don't understand that, the only advice they will usually give is that, 'Oh, you've got diabetes, don't fast,'" he said. "I think that's the wrong message." Still, he added: "Islam does not say you should fast and become a martyr."
El-Sayed is trying to persuade mobile phone companies to help him target diabetes patients and deliver information through text messages. He's also working with international experts on detailed guidelines, to be published next year, on who can and cannot fast.
Doctors said they don't have detailed figures about the health damage suffered by diabetic patients because the most severe cases end up in emergency rooms, not in specialty clinics. But some patients won't be deterred.
Nayel Thnaibat, 65, has failed to manage his diabetes since being diagnosed in 1982. He has lost most of his sight and is bedridden, with one leg amputated above the knee.
Still, he says he'll fast again this year, despite the risks.
"God will protect us," said the retired civil servant who lives with his 60-year-old wife Nofeh, also diabetic, in the southern Jordanian town of Karak. "I will not violate the fast even if I die."