Ramadan is the month-long fast that takes place in the ninth month of the Islamic lunar calendar each year. It is one of the five pillars of Islam. It takes place during daylight hours and is compulsory for all healthy Muslims who have reached puberty. However, there are exceptions to this. Certain groups of people, such as people with diabetes, are exempt. However many people still choose to fast for religious, social and cultural reasons. Studies have shown that as much as 40% of people with type 1 diabetes and around 80% or those with type 2 diabetes will fast during the Holy Month; this adds up to over 115 million people worldwide!
It is a personal choice whether or not you fast. If you do choose to fast, then you must talk to your doctor or diabetes educator first, to make sure that you know how to look after yourself. Fasting can be dangerous if you have diabetes as it can cause health issues, and this would be contrary to the Qur’an, which states that you must not act in a way that harms your body (Al Baqarah Verse: 195).
How fasting may affect blood glucose levels
When we eat, carbohydrates are broken down to glucose and insulin is produced to store the glucose into the liver and muscles.
When we don’t eat for a while, some of this stored glucose in released back into the blood stream with the help of glucagon (another hormone which acts like the antidote to insulin). During long periods of fasting, such as during Ramadan, the blood glucose levels may drop as glucose stores in the body are used up. This can cause hypoglycaemia (low blood glucose levels).
You may develop high blood glucose levels during a fast if you do not take your prescribed medication or if you are less physically active than normal. Large meals at suhur (the dawn meal) and iftar (breaking of the fast) can cause blood glucose levels to spike.
Complications during fasting
Hypoglycaemia and hyperglycaemia are the most common risk factors for people with diabetes who are fasting.
If you have compilations associated with diabetes, such as heart disease, kidney disease or visual problems, the risk of these issues becoming worse during the fast is high, and so you should consider to not fast.
Dehydration and thrombosis
Not drinking any fluids during the day, when you fast can cause dehydration. If you are a person who sweats easily or if you have excessive perspiration due to hard, physical labour, this could get worse quickly. Hot and humid climates, such as during Australian summers, are another risk factor, or if your blood glucose levels are high this can further contribute to dehydration and may increase the risk of thrombosis and stroke.
To Fast or Not to Fast?
Most often the medical recommendation is not to fast. However, 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. If you choose to fast it is important to talk to your doctor about the risks.
You will have to be prepared to break your fast if your blood glucose levels drop below 3.9 mmol/L or rise above 16 mmol/L, to prevent symptoms of hypoglycaemia, hyperglycaemia, dehydration or acute illness.
Blood glucose monitoring
It is important to check blood glucose levels more regularly during Ramadan. Checking blood glucose levels will not break your fast, as there is only a minimum amount of blood involved.
Some dietary points
During Ramadan you should:
- Remember to eat sensibly and healthily
- Never skip suhoor. Long hours without eating increase the risk of hypoglycaemia and it will be much easier to balance your blood glucose levels throughout the fast if you eat a meal at suhoor.
- Try to eat moderate portion sizes – remember that Ramadan is also about self-control and discipline
- Include fruit and vegetables at both suhoor and iftar
- Limit fried or fatty foods. They will make you put on weight, raise your blood glucose levels and make them more difficult to control
- Focus on high fibre carbohydrates
- Limit the intake of salty foods to reduce the risk of dehydration
- Drink plenty of sugar-free fluids, particularly water, at suhoor and after iftar to replenish fluid loss during the day
- Limit your intake of high sugary foods (such as dates or juice, often used to break the fast)
- Ask to see a dietitian who’ll be able to give you more advice about healthy eating.
Supper after tarawih can be taken as a replacement of a pre-bed snack.
You can continue to do your normal physical activity. However excessive physical activity should be avoided as this can increase your 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 hyperglycemia.
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 you could become dehydrated or be at risk of hypos. To avoid problems during Taraweeh, make sure you:
- Eat starchy foods with iftar as they are digested slowly
- Drink plenty of water following iftar
- Take a bottle of water and glucose treatment with you to taraweeh.
Diabetes medications during Ramadan
Although most diabetes medications require no adjustments, some tablets may need to be switched from the morning to the sunset meal. Some medications need to be stopped or changed to reduce your risk of hypoglycaemia. Medications that you usually take three times per day may need to be adjusted so you only need to take them twice per day during the fast.
You should always seek advice from your doctor prior to Ramadan in regards to any medication changes that may be needed.
Basal (sometimes also called background insulin, long or intermediate-acting) insulin doses may need to be reduced by around 15-30%. It is 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 you have a similar sized meal as you would usually have at dinner.
If you take premixed insulin 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 you are usually on three lots of premixed insulin at main meals, the lunchtime one should not be taken. The iftar and suhoor doses will need to be adjusted.
If you have type 1 diabetes and you are on an insulin pump, generally the basal rates will need to be reduced by 20-40% in the last three to four hours of fasting. You should increase your basal rates by up to 30% after iftar. Normal carbohydrate counting and insulin sensitivity principles apply in regards to bolus doses at both suhoor and iftar.
Of course the above medication and insulin dose adjustment recommendations are a guideline only. You should always seek advice from your doctor prior to Ramadan in regards to any medication changes that may be needed.