News and insights brought to you by the International Diabetes Federation

Muslim men gathering for a communal charity iftar organised on a street by a local mosque

Ramadan has a major impact on the management of diabetes in the Muslim population. During the holy month, nothing can enter the body (food-drink-medicine) from dawn to sunset (daylight hours). The impact of fasting during Ramadan on diabetes requires discipline, preparation and the willingness to break the fast if necessary. The question everyone wants to know is: can I fast with diabetes during Ramadan?

Fasting during Ramadan is an obligatory duty for all healthy adult Muslims. Meals are only taken between sunset and dawn. This is called Iftar-literally translated as ‘break fast’. One exception to fasting is for people who are ill or have medical conditions. Even so, many people with diabetes (PWD) insist on fasting during Ramadan.

As of 2015, there were 1.8 billion Muslims in the world, roughly 24% of the global population, according to a Pew Research Center estimate. Approximately 90 to 148 million Muslims live with diabetes worldwide. It has been predicted that Muslims will grow more than twice as fast as the overall world population between 2015 and 2060.

It is critical that healthcare providers (HCPs) and people with diabetes (PWD) are more aware of potential risks associated with fasting. People with diabetes require strategies to mitigate their risk. We asked Professor Abdul Basit, IDF Regional Chair for the Middle East-North Africa region and Professor M. Yakoob Ahmedani, both of Karachi, Pakistan, to answer our questions about managing diabetes during Ramadan.

If people with diabetes have decided to fast, what should they discuss with their healthcare team? ?

In fasting, it is prohibited to have any oral intake-solids or fluids. This is strictly observed. Even if the days are longer or warmer, you can’t drink fluids. People with diabetes who are willing to fast should have a pre-Ramadan session with their HCP. It is important to learn:

  • Their individual risk
  • Medication schedule
  • Blood glucose testing schedule.
  • Ketone testing for type 1 diabetes (if and when needed).
  • Awareness of symptoms such as dehydration, hypoglycaemia and stroke (thrombosis)
  • Seeking help if there is a problem. Intravenous fluids can be administered without breaking the fast.

What are the greatest risks for people with diabetes who decide to fast during Ramadan?

The greatest potential greatest risks for PWD are Hypoglycaemia (low blood glucose) and Hyperglycaemia (high blood glucose), dehydration and stroke.

It is important to highlight that having subcutaneous insulin or intravenous fluids does not affect Ramadan fasting at all. Even intravenous glucose can be given to treat hypoglycaemia without invalidating the fast.

Are the risks the same for type 1 diabetes and type 2 diabetes? If no, what are the differences?

Guidelines suggest that people with type 1 diabetes are at high risk for diabetic ketoacidosis (DKA). There are certainly people who live with type 1 diabetes who should not fast. This includes people with an HbA1c greater than 9%; people who have hypoglycaemia unawareness, renal disease, macrovascular complications and pregnancy. The same rules apply to those with type 2 diabetes.

Many people with type 1 and type 2 diabetes who insist on fasting do well under supervision and with good compliance and backup support.

Is self-monitoring of blood glucose allowed during Ramadan?

Self-monitoring of blood glucose is allowed during fasting. In fact, it improves safety and blood glucose management. People are encouraged to test their more often during fasting. Experts have also almost unanimously confirmed that self-monitoring of blood glucose does not affect fasting. It is also advised to check blood glucose when symptomatic, and to break the fast if blood glucose is <70 mg/dl.

Typically, Ramadan meals are very heavy in calories and also may contain high sugar and high fat foods. What should people with diabetes do during these meals?

The idea that “post fast” at the Iftar meal ought to be heavy is more of a behavioural attitude. Trendy feasting has nothing to do with Ramadan or fasting. In fact it is against the spirit of fasting that people have heavy meals before and after the fast.

Nonetheless, if people have to have higher calories, we suggest medicinal dose adjustments accordingly. In Ramadan, a daily 45 minutes of exercise after Iftar prayer is commonly observed. This is a good starting point for those who are not exercising regularly to develop an exercise plan after Ramadan. Furthermore, there is an evidence that those overweight who comply to the dietary advice, lose weight significantly during Ramadan.

How can healthcare professionals help guide people living with diabetes who decide to fast?

Key components of a Ramadan-focused educational programme include: risk quantification, blood glucose monitoring, fluids and dietary advice, exercise advice, medication adjustments, and when to break the fast.

How can a person with type 2 diabetes on orals manage medication?

It has been discussed above that any oral intake breaks the fast. Hence, taking any medication orally is not allowed during fasting. Please note that fasting is from dawn to dusk and therefore usual oral medications taken once or twice a day can be taken during Ramadan from dust to dawn. If hyperglycaemia prevails during the day, an insulin injection can be taken. It is always best if the PWD speaks to a HCP for planning their fast.

What types of guidelines should people follow should they need to adjust their medications? Where can they find this information?

People with diabetes can benefit from the DAR Safa app.

Where can professionals get more information?

Many countries have developed their own websites and literature customised to their community needs. We in Pakistan recommend for Pakistani population, in particular.

Prof. Abdul Basit is Director, Baqai Institute of Diabetology & Endocrinology (BIDE), Karachi, Pakistan; and Chair, IDF Middle-East and North Africa Region 2018-19.

Prof M. Yakoob Ahmedani is affiliated with Baqai Institute of Diabetology & Endocrinology, Karachi, Pakistan; and Chair, Pakistan Diabetes in Ramadan Group



Elizabeth Snouffer is Editor of Diabetes Voice

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