Overview

Fasting during Ramadan is obligatory for all Muslims. However, there are some exemptions for people with chronic conditions like diabetes. Despite potentially being exempt, many people with diabetes choose to fast. Managing diabetes during Ramadan fasting can be challenging and can in crease various health concerns for diabetic patients. It is there fore important to discuss with the doctor before deciding to fast or not. The doctor can help to decide while taking into account the severity of the illness and the level of risk involved in fasting with diabetes during Ramadan.

Today, we will be learning about diabetes management during Ramadan from Diabetologists - Dr. Hira Baqai and Prof Dr. Muhammad Adnan Kanpur wala.

The Risks of Fasting with Diabetes

According to Dr. Adnan, “It is important to check the status of the diabetic patient, type of diabetes (Type 1 or Type 2),any complications, blood pressure and heart condition of the patient before advising the patient to fast or not.” After a thorough check-up, if the patient is able to control the sugar level, the doctor will advise on how to manage the condition throughout the fasting period.

People with diabetes who are at high or moderate risk are advised not to fast as they might develop complications when fasting during Ramadan. These high-risk patients include Type 1 or Type 2diabetes with poor blood sugar control, history of severe low blood sugar, kidney or heart disease and whether their blood sugar has been well-controlled for a significant period, among other factors. However, people at low risk can fast according to the guidelines given by their doctor.

Fasting with diabetes can lead to several complications that include:

• Low blood glucose (hypoglycemia)
• High blood glucose (hyperglycemia)
• Increase in uric acid due to less water intake
• Dehydration and thrombosis (blood clots)
• Diabetic ketoacidosis (DKA), in people with type 1 diabetes
  

The doctor considers the following before advising to fast in Ramadan with Diabetes:

• The type of diabetes
• Maintaining average blood sugar level in a healthy range(HbA1c level less than 58 mmol/mol)
• The type of medication used to control diabetes
• If you take medications that put you at risk of hypo glycemia such as insulin

If you're living with diabetes complications such as poor vision, nerve damage, heart or kidney disease. There is a high risk that fasting could make these health conditions worse.  

Most people with type 2 diabetes can fast safely with appropriate medical advice and management before and during fasting. However, people with type 1 diabetes need special attention. For example, people living with type 2 diabetes who manage with diet and lifestyle only, or who take one diabetes medication will have a lower risk of complications during the fast, if they are already keeping their average blood sugar level (HbA1c)in a healthy range. Moreover, pregnant women diagnosed with diabetes are advised not to fast.
Once cleared for fasting, patients will need to check their blood sugar several times a day, Dr. Adnan says, as the levels can fluctuate significantly when the body enters into a fasting state and after breaking the fast.

Tips for a Healthy Ramadan with Diabetes

1. Visit the doctor prior to Ramadan
It is recommended to know the risks before deciding to fast. Visiting the doctor 6 to 8 weeks prior to Ramadan will help you to understand your risk category before deciding to fast. If the doctor allows, he/she will give details about nutrition and medication to be taken according to the diabetic status.

2. Check your blood glucose regularly
Blood glucose monitoring and insulin injections do not break the fast.  It is recommended you check your blood sugar levels frequently throughout the day; this is especially critical for patients who require insulin. Changes in eating habits during Ramadan may affect your blood glucose and therefore it is important to check glucose levels regularly.

• People at very high risk (even if not fasting) should check blood glucose levels 3 to 4 times a day.
  1.  Between10:00 am and 11:00 am
  2. Between3:00 pm and 4:00 pm
  3. 3hours after iftar
  4. Directly before suhoor

• People at moderate or low risk should check blood glucose levels 1 to 2 times a day

3. Medication adjustments during fasting
Talk to your doctor about the adjustments required to the dose, timing or type of medication to reduce the risk of low blood sugar. Patients taking insulin should be instructed on self-monitoring of blood glucose and individual adjustment of insulin doses based upon glucose goals discussed before commencing Ramadan.

4.  Nutrition
A healthy and balanced diet during Ramadan is recommended for everyone, but especially for those who have diabetes or are pre-diabetic. Dr. Hira explains that people with diabetes might have low blood sugar during fasting, for this reason, it is recommended to have a healthy diet during suhoor and iftar.

A perfect suhoor could include – milk, home made chapati with curry, a date, yogurt, oats/cereals, salads and tea without sugar. Avoid processed food items and sugary fizzy drinks and fruit juices in both suhoor and iftar as these will raise your blood sugar and make you feel thirstier.  

Dr. Hira advises drinking at least 1.5 to 2litres of water from iftar till suhoor to avoid dehydration. Moreover, it is advised to take high fibre starchy foods in suhoor like cereals or oats, beans, chickpeas, wheat, brown rice or even a glass of Ispagol (fibre) which are low glycemic. These will help keep your blood sugar levels in a safe range while you are fasting.

A healthy iftar can include a date, salted lassi or lemon water without sugar, a calcium supplement drink, a fruit bowl without sugar and no fried and oily items, as these can increase your blood cholesterol and blood pressure above healthy levels.

5. Exercise
Regular or light exercise and walking for 20 to30 mins daily are allowed during Ramadan for most diabetics who choose to fast. Rigorous exercise is not recommended during fasting because of the increased risk of low blood glucose and/or dehydration. Although, exercise during fasting hours, especially before iftar, is generally discouraged as it may lead to hypoglycemia. It is advisable to rest before iftar; however, people with diabetes are advised to avoid sleeping during this period in order to remain alert to signs of hypoglycemia (which is more likely to occur during the later hours of the fasting day).
6. Break the Fast
All people with diabetes should break the fast if:
Blood glucose is lower than 70 mg/dl (3.9 mmol/L)
Blood glucose is higher than 300 mg/dl (16.6 mmol/L)
Symptoms of low blood sugar (for example, feeling dizzy, sweaty or shaky, blurred vision)
Symptoms of acute illness (for example, vomiting or diarrhea)

Conclusion

Managing diabetes during Ramadan is all about smart management and making healthy choices. Nevertheless, before deciding to fast, it is important to talk to your doctor to see how you are currently managing your diabetes.  The doctor will explain the potential risks of complications such as low or high