As the holy month of Ramadan has approached, we will be fasting to please Allah, while a degree of hardships are expected, Allah does not want anyone who is fasting to harm themselves in the process. Nevertheless, many patients with diabetes insist on fasting which can be a complex undertaking for treating doctors, requiring a delicate balance between religious observance and health management.

This article explores the challenges, considerations, and strategies for those navigating the intersection of diabetes and Ramadan. Fasting during Ramadan can disrupt the routine of diabetes management.

Prolonged periods without food can lead to fluctuations in blood sugar levels, potentially causing hypoglycemia or taking lots of calories together at iftar can lead to hyperglycemia. Individuals with diabetes must weigh their spiritual commitment against potential health risks.

Pre-Ramadan preparation and planning should focus of six key areas.

RISK QUANTIFICATION

Certain circumstances, such as unstable blood sugar levels, severe complications, or specific health conditions, may exempt individuals from fasting. It is crucial for individuals to recognize and respect these exceptions, prioritizing their health over strict adherence to fasting practices. Patients with uncontrolled or high blood sugars before Ramadan, previous history of hypoglycemia, complications related to diabetes, ketoacidosis, foot ulcers, associated cardiovascular diseases should refrain from fasting as it can cause life-threatening consequences.

Risk stratification during fasting:

Very Low risk

Diabetics who are on diet control and on oral hypoglycemic drugs like

Metformin and Thiazolidinediones, with controlled blood sugars

Low risk

Diabetics who have well controlled blood sugars, and on short acting insulins and Secretagogues

High risk

Diabetics with HbA1c of 7.5-9 mg %, elderly, living alone , with co -morbidities, on narcotic drugs, kidney diseases, diabetic complications or on multiple drug therapies, combination of  sulphonulyurea and Insulin make them more prone for life threatening conditions in Ramadan

Very High risk

Type 1 Diabetics who had episodes of recurrent hypoglycemias and ketoacidosis in previous 3 months, uncontrolled blood sugars with HbA1c of more than 9 mg%. Diabetics on dialysis, doing heavy labour work and recently been admitted on seeking treatment for any acute illnesses like lower respiratory track infections, acute gastroenteritis etc. Always seek your doctor’s opinion for risk stratification before fasting.

 BLOOD GLUCOSE MONITORING:

Regular monitoring of blood sugar levels is imperative during Ramadan. Continuous communication with healthcare providers can help individuals make informed decisions about insulin dosage and medication adjustments based on their daily observations. Self-monitoring of blood glucose (SMBG)should be encouraged in diabetics in Ramdan to keep tract of their blood sugars for proper monitoring and interventions if needed.

 EXERCISE MANAGEMENT

Maintaining a reasonable level of physical activity is essential for overall health but requires thoughtful planning during fasting. Engaging in light exercises during non-fasting hours and avoiding intense activities during fasting can contribute to a balanced lifestyle. Exercise should be done 2-3 hours before or after iftar, not exceeding 30 minutes. Diabetics on sulfonylureas and insulin should be more careful as these drugs can cause hypoglycemia so exercise benefit should outweigh the hypoglycemia.

MEDICATION ADJUSTMENTS

For some individuals, adjustments to diabetes medications may be necessary during Ramadan. This emphasizes the importance of close collaboration between individuals with diabetes and their healthcare providers to ensure optimal management. Patients on metformin may fast safely because possibility of severe hypoglycemia is minimal. Glitazones and GLP-1(Glucagon like peptide 1) are not independently associated with hypoglycemia but can amplify hypoglycemic effects of sulphonulyurea, glinides and insulin. Short acting secretagogues are useful because of short duration of action. Using one injection of a long-acting or intermediate-acting insulin can provide adequate coverage in some patients as long as the dosage is appropriately individualized; however, most patients will require rapid- or short-acting insulin administered in combination with the basal insulin at meals, particularly at the evening meal, which typically contains a larger caloric load in Ramadan.

DIETARY ADVICE AND HYDRATION

Having a balanced diet with low Glycemic index (GI), healthy fats and proteins are very important for the efficient blood sugar control and prevention of hypoglycemia in Ramadan. Glycemic index (inherited quality of the to raise blood sugars) should be taken into consideration while choosing the appropriate diet.

Suhoor and iftar

Don’t skip the Suhoor, as it helps provide sustained energy throughout the day and prevents from potential blood sugar imbalances Eating complex carbohydrates at suhoor which include whole grains like oats, brown rice, or whole wheat bread with low GI to provide sustained energy throughout the day, lean protein sources such as eggs, yogurt, or legumes to promote satiety. Healthy fats like nuts, seeds, avocados, or olive oil for additional energy and nutrient absorption. Hydration is also essential, especially during non-fasting hours. Consumption of caffeinated and carbonated drinks should be avoided. Add a variety of colourful vegetable for fibers, vitamins and minerals. Choose whole grains such as brown rice, or whole wheat for sustained energy. Incorporate nuts, seeds or olive oil in moderation.

TO KNOW WHEN TO BREAK THE FAST WHEN NEEDED

All patients should understand that they must always and immediately end their fast if hypoglycemia (blood glucose of<60 mg/dl occurs because their blood glucose may drop further if they delay treatment. The fast should also be broken if blood glucose reaches <70 mg/dl in the first few hours after the start of the fast, especially if insulin, sulfonylurea drugs, or meglitinide are taken at predawn. Finally, the fast should be broken if blood glucose exceeds 300 mg/dl (16.7 mmol/l). Patients should avoid fasting on “sick days.”

Dos for Diabetics in Ramadan:

Seek advice from healthcare providers before fasting

Focus on what you eat

Hydrate well during non-fasting hours

Engage in light physical activity

Choose nutrient dense foods

Don’ts for Diabetics in Ramadan:

Skip the Suhoor

Overindulge in high-sugar or high-fat foods during Iftar

Adjust medications without consulting healthcare professionals.

Ignore symptoms of hypoglycemia (low blood sugar) or hyperglycemia (high blood sugar).

Promptly address any abnormal symptoms and seek medical advice if needed

TAKE AWAY MESSAGE

Ramadan is a thoughtful and individualized approach, including regular monitoring, balanced nutrition, hydration, and collaboration with healthcare professionals to ensure a safe and spiritually fulfilling fasting experience.  The 5 R’s for Ramadan are Respect patient’s wishes, Risk stratification, Revision of therapy, Regular follow up, Reappraisal of therapy.

By Dr. Mohammad Hayat Bhat and Dr Naira Taban

Dr. Mohammad Hayat Bhat and Dr Naira Taban, Department of Endocrinology, Government Medical college, Shereen Bagh