Ramadan is one of the five pillars of Islam, it is the month-long fast that takes place in the ninth month of the Islamic lunar calendar each year. The end of Ramadan is marked by Eid ul Fitr, the festival of breaking the fast.
Ramadan takes place during daylight hours and is compulsory for all healthy Muslims who have reached puberty. Although certain groups of people, such as people with chronic conditions like diabetes and pregnant women, are exempt, many people still choose to fast for religious, social and cultural reasons.
Many Muslims with diabetes are passionate about fasting. They enjoy the spiritual atmosphere during Ramadan, don’t think of themselves as being sick and don’t want to miss out. Ramadan is a time to learn how to manage eating habits, improve self-control and discipline, and sympathise with the poor.
Studies have shown that up to 40% of people with type 1 diabetes and around 80% of people with type 2 diabetes will fast during the Holy Month.
The decision to fast is personal, and as a member of the diabetes health care team you have a duty of care to respect your client’s commitment to fast and ensure their safety.
It is recommended that people with diabetes who plan to fast during Ramadan talk to their doctor or diabetes educator to ensure that they know how to look after themselves.
For people with type 1 diabetes, women who are pregnant or for those with unstable diabetes management or hypoglycaemia unawareness prior to Ramadan, it is generally not recommended to participate in the daylong fast due to the increased risk of complications.
As a healthcare professional you should take an active role in discussing Ramadan with clients as refraining from eating and drinking and using medications, including insulin, affects blood glucose levels and can lead to potential risks including hyperglycaemia, hypoglycaemia, dehydration, blood clots and diabetic ketoacidosis (DKA).
A pre-Ramadan assessment is an opportunity to review blood glucose levels, blood pressure and lipids, discuss any potential risks of fasting, discuss the importance of more frequent blood glucose monitoring and how to treat a hypo or manage high BGLs, as well as prescribe any Ramadan-specific changes in the dose and/or timing of medications or the insulin regime.
During Ramadan a person’s eating pattern will endure a major change, due to long gaps between meals and feasting after iftar, and this can lead to greater swings in blood glucose levels. Proper nutrition is important to prevent health problems and eating during Ramadan should therefore not be significantly different from healthy eating during the rest of the year.
Strategies for safe fasting
Monitor blood glucose levels – check blood glucose levels more frequently, particularly if on insulin or on sulfonylureas. Checking BGLs does not break the fast.
Normal physical activity can be maintained, however, too much or vigorous physical activity while fasting can lead to hypoglycaemia and dehydration
Be prepared to break the fast in case of hypoglycaemia
Participants can break their fast with the Prophetic tradition of dates, water and a bowl of soup as these will provide an instant energy boost and hydration, to help settle hunger and prevent overeating at the main meal. It is recommended to only have 3 dates (which equal 1 carbohydrate exchange).
Fluid intake is important to prevent dehydration. Participants should aim to drink 2 cups of water each hour past sunset and aim to drink two and a half litres of fluid by suhoor.
It is normal to feel hungry 2 hours after iftar, participants should avoid overeating traditional sweets and should choose healthier snack options such as 100-200g low fat yoghurt, 1-2 pieces of fruit, a cup of low fat milk, a wholegrain salad-and-cheese or tuna-and-salad sandwich, a handful of (unsalted) nuts, or some hummus dip with vegetable sticks.
Participants can continue to do their normal physical activity. However excessive or vigorous physical activity should be avoided as this can increase the risk of hypoglycaemia, particularly during the few hours before the sunset meal.
In some patients with poorly controlled type 1 diabetes, exercise may lead to severe hyperglycaemia.
Taraweeh (multiple prayers performed after the sunset meal which involve repeated cycles of rising, kneeling, and bowing) should be considered a part of the daily exercise program. Taraweeh can be a tiring activity and the person participating could become dehydrated or could be at risk of hypoglycaemia. To avoid problems during Taraweeh, participants should make sure to:
Eat low GI, starchy foods with iftar
Drink plenty of water following iftar
Take a bottle of water and glucose treatment to taraweeh
Although most diabetes medications require no adjustments, some oral agents may need to be switched from the morning to the sunset meal. Some medications need to be stopped or changed to reduce the risk of hypoglycaemia. Medications that are usually taken three times per day may need to be adjusted so they only need to be taken twice daily during the fast (at suhoor and at iftar).
Basal (background, long or intermediate-acting) insulin doses may need to be reduced by around 15-30% and are often best taken after iftar.
Bolus (mealtime, rapid or short-acting) insulin doses should not be taken at lunchtime. The suhoor dosage may need to be reduced by around 25-50%. Usually the regular bolus dosage can be continued at iftar, provided the person has a similar sized meal as they would usually have at dinner.
If premixed insulin is prescribed once daily the dosage can be taken at iftar. For those taking twice daily premixed insulin, the suhur dosage will need to be reduced by around 25-50%. If premixed insulin is prescribed three times daily with each of the main meals, the lunchtime dosage should be omitted. The iftar and suhoor doses generally will need to be adjusted.
If the person wanting to fast has type 1 diabetes and are on an insulin pump, generally the basal rates will need to be reduced by around 15-30% throughout the day and by around 20-40% in the last three to four hours of fasting. Generally, basal rates will need to be increased by up to 30% after iftar for a few hours. Normal carbohydrate counting and insulin sensitivity principles apply in regards to bolus doses at both suhoor and iftar.
Of course these medication and insulin dose adjustment recommendations are a guideline only.
Full recommendations for the management of diabetes during Ramadan can be found here
To learn more about Ramadan your clients may like to review the following articles: