Managing diabetes during Ramadan
Ramadan is the Islamic holy month where fasting is compulsory for all healthy Muslims. Absolute fast between sunrise and sunset is recommended and people who are fasting should refrain from:
There are no restrictions on medications, food or fluid intake between sunset and sunrise. People fasting during this month can have two meals per day:
Sehri (before dawn)
Iftari (after sunset)
Ramadan is a lunar-based month which occurs earlier each year and over the coming decade, the number of fasting hours will progressively increase, especially in the northern hemisphere as Ramadan falls in the summer months. The duration of the fast can vary from a few hours to more than 18 hours, depending on the country you live in.
Ramadan is mandatory for healthy Muslims but exempted for:
Acute medical illness
Pregnant or nursing mothers
People with chronic illness (e.g. diabetes, chronic kidney disease, cardiovascular disease)
Patients with diabetes are exempted from fasting during Ramadan if they are at high risk of complications. However many Muslims with diabetes insist on fasting during Ramadan and their wishes should be respected, if it is safe to do so. This creates a medical challenge for both patients and physicians.
Muslims with diabetes who should NOT fast include those who:
- Have an unawareness of hypoglycaemia
- Have type 1 diabetes with recurrent ketoacidosis
- Have gestational diabetes
- Are pregnant or lactating
- Are menstruating
- Have infections
- Are children
- Have any other illness complicating diabetes
- Are elderly
If people with diabetes with any of the above conditions still want to fast, they should consult their diabetes doctor/nurse and their local Imam.
So, once you have decided on fasting, you should plan well ahead of Ramadan. Fasting during Ramadan not only uplifts you spiritually and physically but also helps you to significantly improve your blood glucose control and your body weight.
Please consult your diabetes specialist team to undergo pre-Ramadan assessment and receive a structured education related to physical activity, meal planning, glucose monitoring and dosage/ timing of medications.
The most important aspect in diabetes management during Ramadan is to prevent hypoglycaemia or low blood glucose (below 4mmol/l or 72mg/dl). In order to prevent hypoglycaemia, a management plan must be individualised to your needs and practiced at least a month or two before Ramadan. If you do have hypoglycaemic episodes requiring correction with food, liquids or medications, you can always compensate by fasting at a later date or feed the hungry and poor (Fidyah).
Management of your diabetes during the month of Ramadan depends on how you are being treated for your diabetes. People with diabetes may be treated with:
- Diet alone
- Sulphonylureas like glyburide, gliclazide, glibenclamide
- Gliptins like saxagliptin, sitagliptin, linagliptin
- GLP-1 analogues like Victoza, Bydureon, Lyxumia
- SGLT-2 inhibitors like Forxiga, Invokana and Jardiance
DO NOT make any changes to your treatment, until you have consulted your doctor
It is generally recommended that those who have diet controlled diabetes and those who are on metformin, acarbose, pioglitazone (Actos) or gliptins need not make any changes to the dose. However some people may need a reduction in dose.
Dosage adjustment is needed for people taking sulphonylureas and insulin. Some people need to either reduce dose or stop sulphonylureas in the morning.
Change or reduction in dose of insulin depends on the type of insulin, blood glucose levels and duration of fasting. Generally people take one third of their daily dose in the morning and two thirds of the evening dose after breaking their fast. However this varies greatly and hence dose change should be individualised.
As you can see there are a vast number of variations so it is important that you ALWAYS CONSULT YOUR DOCTOR BEFORE MAKING ANY CHANGES.
If you are prone to hypoglycaemia do check your blood glucose frequently.
People with Type 1 diabetes, Should NOT stop insulin and ALWAYS consult a doctor before making any changes.
Most people find fasting difficult during the first week of Ramadan since your brain needs glucose to function normally. During fasting, sugar intake could be reduced and your body breaks down the glycogen stored in your liver to glucose. After a few days, when all the glycogen is used up, your body breaks down the fat, producing ketones. Ketones suppress your appetite so increased ketones are produced after the first few days and you start to feel less hungry. People with diabetes may find that their blood glucose is different in the first week compared to the rest of the weeks in Ramadan and hence will need close monitoring and the altering of the dose of medications appropriately.
If you are involved in any physical activity, discuss with your doctor or nurse and alter your medications as appropriate. Please click here if you need help with weight loss. For a weight loss menu, which could be followed during the month of Ramadan, please click here.