Fasting during Ramadan is obligatory for all healthy adult Muslims. There is often an intense desire to fast even in those who are eligible for exemption.
Many individuals with diabetes will be eligible for this exemption, however safe fasting with diabetes is possible.
Often patients with diabetes avoid consulting health professionals during Ramadan, usually due to the perceived threat of advice against fasting.
However it is important for patients to consult their doctors prior to Ramadan to ascertain their risk and formulate an individualised management plan.
Diabetes mellitus is a complex condition in which the body cannot maintain healthy glucose levels in the blood. Insulin, a hormone produced by the pancreas, is important in helping the body to utilise glucose for energy.
Type 1 diabetes (T1DM) is an autoimmune condition that affects approximately 10% of people diagnosed with diabetes. It occurs when the pancreas is unable to produce any insulin.
All patients with T1DM require insulin treatment and omission during fasting is dangerous.
Type 2 diabetes (T2DM) usually develops when insulin cannot work properly or the body becomes ‘resistant’ to the insulin that is produced.
Often patients with T2DM will be on tablets to control their blood glucose level but may also require insulin treatment.
Diabetes that is not well controlled can be associated with a range of long-term complications including heart disease, kidney disease, blindness and amputations.
The global prevalence of diabetes continues to rise with in excess of 400 million people living with diabetes worldwide. India, Indonesia, Egypt and Bangladesh are in the top ten countries with the highest number of adults living with diabetes.
In addition, there is a disproportionately high prevalence of diabetes in Muslim-majority nations. Studies have shown that approximately 40% of patients with T1DM and 75% of patients with T2DM fast for at least 15 days during Ramadan.
Fasting with diabetes
There are many physiologic changes that occur during Ramadan related both to the fasting itself and the altered sleep-wake cycle.
Overall total body weight typically decreases or remains stable during the holy month.
During fasting blood glucose levels fall and insulin production is reduced.
In healthy individuals, the liver can release glucose from stores for approximately 12 hours before fat stores are utilised for energy.
Patients with diabetes have reduced capacity to cope with both prolonged fasting as well as excessive feasting at iftar.
The risks or severe hypoglycaemia (low blood glucose), severe hyperglycaemia (high blood glucose), dehydration and metabolic complications (eg diabetic ketoacidosis) are particularly heightened.
Can people with diabetes fast?
It depends. The decision to fast is a personal one and certainly many people with diabetes are exempt.
The decision will also be influenced by geographical location and the expected duration of fasting.
If fasting is expected to be greater than 15 hours per day then fasting all days will likely be difficult.
There are particular characteristics, which place patients at high risk:
- Patients at risk of hypoglycaemia
- Patients treated with insulin are at highest risk
- Patients taking medications in the sulfonylurea class (eg gliclazide, glipizide, glibenclamide, glimepiride). These medications act by stimulating insulin secretion from the pancreas. Other types of diabetes medications do not cause hypoglycaemia but can increase the risk if taken in combination with insulin or a sulfonylurea.
- Patients with poorly controlled type 1 diabetes
- Patients on dialysis or severe kidney disease
- Elderly patients with ill health
- Pregnant patients
- Older people are particularly vulnerable to diabetes related complications during Ramadan, however many have enjoyed fasting for many years without issues.
Their risk should be assessed by the presence comorbid illnesses, functional capacity and cognitive function. Old age alone is not considered dangerous.
What can be done?
It is vital that patients with diabetes work with their treating clinicians (Endocrinologist and/or GP) to create an individualised diabetes management plan that is safe for the month of Ramadan.
It may not be possible for all people with diabetes to fast. Detailed guidelines have been formulated by the International Diabetes Federation in collaboration with the Diabetes and Ramadan International Alliance to facilitate management of patients during fasting.
Practical tips and recommendations:
- See your doctor (Endocrinologist or GP) to create a diabetes plan for the month of Ramadan BEFORE commencing fasting
- Maintain contact with your doctor to trouble-shoot any problems that arise
- It is most important for patients to check their blood glucose levels regularly during fasting. This may be numerous times per day depending on individual circumstances and risk of hyper and hypoglycaemia.
- Often the treatment regimen will need to be changed for fasting days. For example pre-mixed insulin (a combination of long and short acting insulin) may need to be changed to separate long and short acting components. Insulin doses may need to be reduced.
- Certain medications may need to be dose-reduced or ceased temporarily.
- Always carry glucose treatment when travelling and be willing to break the fast if necessary.
When to break the fast:
- Blood glucose less than 4.0 mmol/L
- Blood glucose greater than 16.6 mmol/L
- Symptoms of hypoglycaemia (eg trembling, sweating, palpitations, confusion), hyperglycaemia (eg extreme thirst, hunger, frequent urination, nausea/vomiting), dehydration or other illness
Contact your doctor to prevent further complications before resuming fasting
- Avoid eating very large meals at iftar which can cause hyperglycaemia
- Avoid eating significant amounts of processed carbohydrates, sugar, desserts or fried foods at suhoor or iftar
- Avoid sugary drinks and caffeinated beverages
- Begin iftar with plenty of water and 1-2 dates to raise the blood glucose level
- Eat balanced meals consisting of low GI carbohydrates 45-50%; protein 20-30% (eg legumes, fish, meat); and fat <35% (mono and polyunsaturated preferred)
- Eat plenty of vegetables
- A diet plan for Ramadan can be created with your GP, Endocrinologist or dietician
The majority of patients with diabetes can be safely managed during Ramadan if adequate education is provided before, during and after Ramadan.
It is important for patients, old and young, to involve their treating clinicians in their diabetes management to avoid unnecessary risks of fasting.