News and insights brought to you by the International Diabetes Federation

Women having dinner during Ramadan

Fasting (Sawn or Roza) during the holy month of Ramadan is one of the five pillars of Islam and commemorates the time when the Holy Quran was revealed to Prophet Muhhammad (PBUH). The month-long (29-30 day) fast is obligatory for all healthy Muslims who have reached puberty. Followers must refrain from eating and drinking between dawn and sunset, and must abstain from using oral medications, sexual activity and smoking.

Fasting is mandatory for all Muslim adults, with certain groups exempt, including some people with chronic conditions like diabetes. Despite potentially being exempt, many people with diabetes choose to fast.

With Ramadan currently being observed around the world, we asked people with diabetes from different countries to share their story of how Ramadan impacts their daily lives and management of their condition.

Cyrine, Kawter, Ehab and Shakir
From left to right: Cyrine, Kawter, Ehab and Shakir
Cyrine Ferhat – Lebanon

I’ve been living with type 1 diabetes for the past 13 years. I’m currently happily married and on top of everything diabetes-related. I fasted for four years before I was diagnosed with diabetes at the age of 15. I stopped fasting after I was diagnosed. My endocrinologist advised me against it as she feared I would have hypoglycemia. It honestly felt like my healthcare team was making the decision for me.

They informed me how dangerous it might be to fast, not only to my glucose levels but to my entire physical well-being. Honestly, my healthcare team was the only reason I took the decision to begin with and they have continued to advise me against fasting. My family and friends also pushed me not to fast as they all believed it would do me more harm than good. People who care a lot for me obviously want me to be in good physical health and emotional well-being. They have therefore always managed to normalise the fact that I wasn’t fasting and have constantly motivated me as they all believe it is to my best advantage.

Honestly, it’s very hard not too fast, especially if you’re a very spiritual person and into the whole atmosphere of Ramadan. During Ramadan, I basically switch to having only two meals per day. I have a very small breakfast, lots of fluid throughout the day and a major meal with the family at night. It’s always awkward when a person with diabetes is invited over for Iftar to someone’s feast, especially if they don’t know that you have diabetes.

We should always remind ourselves that we come first, our health comes first and everything else we do should be centered around that.

The worst memory I can think of is when I once had hypoglycemia just before the break of the fast. I had to get myself a juice and drink it among a very hungry, thirsty and tired group of fasting people, who were all staring at me. Once my blood glucose levels settled, I explained my situation. However, it didn’t make the whole experience any less awkward. It’s very challenging to be a person with type 1 diabetes living among people who are fasting and not join in the process, but we always have to bear in mind that it is for our best advantage, to stay as healthy and safe as possible.

Therefore, it shouldn’t push us backwards or make us feel any less of a person. We should always remind ourselves that we come first, our health comes first and everything else we do should be centered around that.

Kawter Eshneen – Libya

I’m a General Practitioner at Tripoli Children’s Hospital. I have been living with type 1 diabetes for 19 years. My life with diabetes was difficult at the beginning but, with experience and education, everything is now going fine. I always fast during Ramadan. It’s an important part of our region and religion.

Fasting during Ramadan helps us get an idea of what homeless and poor people feel. It also helps make us healthier and feel more fit and active.

Our health team spends around two months before Ramadan preparing people who want to fast. We conduct a lot of workshops and lectures to explain the rules for fasting during Ramadan and what is important. We also do check-ups and measure HbA1c to make sure that the people with diabetes can fast safely during Ramadan.

Fasting with diabetes is not impossible and can be done safely and comfortably with the help of the healthcare team, family, friends and colleagues.

The most difficult thing during fasting is dealing with hypoglycemia. It’s also hard to have to break the fast. It gets easier with a continuous glucose meter and insulin pump, which help us to predict and correct episodes of low blood glucose.

My family, friends and colleagues help me to manage and take care of my diabetes during the fast. They help me to rest, make sure that I don’t get stressed when working and generally feel comfortable.

I’ve been fasting with diabetes for 16 years and, during this time, I’ve never had to break the fast. However, should I need to in future, I will do it.

Fasting with diabetes is not impossible and can be done safely and comfortably with the help of the healthcare team, family, friends and colleagues.

Ehab Ali – Bahrain

I am 26 years old and have been living with type 1 diabetes since the age of 21. I have been fasting for Ramadan since my diagnosis. It is something very important for us religiously, the second main element after prayer. Although I can be exempt from fasting and it changes my life for one month, I feel happy and satisfied when I fast and would feel guilty if I didn’t.

My healthcare professional played an important role during the first year after my diagnosis. Since then, her support has been less but she has always been there when I’ve needed help to make dose adjustments. Keeping my blood glucose in control, especially to avoid hypos, has always been the main concern.

At the beginning of Ramadan, I usually decrease my long and rapid-acting insulins as low as possible to avoid hypos, which as a result increases my blood glucose during the first hours of fasting. It takes me a few days to adjust my doses accordingly. The person with diabetes is best placed to understand their diabetes and how their body reacts to certain foods and activities. You have to be responsible for yourself.

Usually, you get invited to many meals, most of which are unhealthy. When you feel responsible for yourself, you’ll be able to manage your diabetes and keep it under control. My family and friends always support me and make sure that I eat enough food to avoid feeling tired during the fasting period. However, sometimes they cook very delicious meals that can make my diabetes harder to manage. Family and friends will also invite you for Iftar and Suhoor out of charity and generosity, which can make your blood glucose go up and down like a roller coaster.

Although I can be exempt from fasting and it changes my life for one month, I feel happy and satisfied when I fast and would feel guilty if I didn't.

In the first couple of years, I used to break my fast in the middle of the day, due to hypos. I’m now using a CGM device which makes it easier to manage hypos without breaking the fast. However, when I have to do a physical activity at the beginning of the day and get a hypo, I usually break the fast and make up for it another day after Ramadan.

I remember that in the first year after my diagnosis, I looked for a doctor to give me guidance on what to do and how to live with diabetes during Ramadan. I found a professor and was very hopeful that he would have all the answers, telling me what to eat and what to do. When I visited him, he told me, “Son, you have to read a lot of books.” I answered, “Sure, but regarding eating, what can I do?” He replied that there was nothing that he could do for me and that I had to read. I felt that I had wasted my time and money, but years later, I discovered that he was right. I have learnt more about diabetes from reading and getting to know other people with diabetes, than I have from doctors.

Shakir Mansoor Khan – Pakistan

I am 48 years old and was diagnosed with type 2 diabetes two years ago. There was a genetic reason because both my parents were living with diabetes.

Diabetes was nothing new for me as I was a caregiver for my parents and, professionally, I have been involved with a company dealing with medicines for diabetes management. Throughout my life I have fasted and so did my parents, who were living with diabetes. It is really important for me to fast during Ramadan. The spiritual aspect is one of the reasons and I also strongly believe that fasting improves overall body metabolism and reduces insulin resistance.

I believe that for people with diabetes, the role of the healthcare professional and caregiver is a very important, especially during Ramadan. They can guide us, particularly for the Sahoor and Iftar meals. We need to adjust the medications that we we take during Ramadan. I normally consult my healthcare professional before and during Ramadan, regularly sharing my glucose levels. During Ramadan, all family members get together, especially for Iftar.

The most important thing is that people with diabetes should consult their healthcare professional.

I see a lot of things to eat, like French fries and chicken, so, personally, compared to my family members, the experience can be a bit hard for me. It’s all about your personal commitment to yourself and managing your condition. I normally eat fresh fruits and drink soda water rather than any sugary drinks. Taking Suhoor is very important during Ramadan. A person should eat a good meal at that time so that they can spend the next 10 to 12 hours fasting.

My family members are very supportive. They make special vegetarian meals for me, remind me to check my blood glucose and go to my healthcare professional. Understanding diabetes and its complications is really important for the person affected.

I have never had to break my fast due to a hypoglycemic event, but my mother, who was treated with insulin, did have to sometimes. It is also mentioned in Islam that if someone is not feeling well or living with a chronic disease, they are exempt from fasting. It is very flexible as well.

During my professional experience, I have seen many cases of people with diabetes with very high levels of blood glucose. They did not know that it was really important to check their blood glucose level on a regular basis. The most important thing is that people with diabetes should consult their healthcare professional.

Cyrine Farhat, Kawter Esheenn, Ehab Ali and Shakir Mansoor Khan are members of the IDF Blue Circle Voices network

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