Precautions on Diabetes and Ramadan Fasting

Physicians face the difficult task of advising their Muslim diabetic patients whether it is safe to fast, as well as recommending the dietary and drug regimens diabetics should follow. The lack of adequate literature on this subject makes it more difficult to answer these questions.
If you are a physician, read this review article intended is to assist physicians who face the difficult task of advising diabetic patients about the safety of fasting during the Islamic month of  Ramadan. There have been diverse findings regarding the physiological impact of Ramadan on  diabetics. However, researchers have not found pathological changes or clinical complications in any of the following parameters in diabetics who fast: body weight, blood glucose, HbA1C, c-peptide, insulin, fructoseamine, cholesterol and triglycerides.
If you are a patient, first you should understand the basics of normal diet for pateints of diabetes (click here to read) .
 As per the opinion of doctors and findings in the famous research by Dr Fereidoun Azizi, MD, and Dr  Behnam Siahkolah, MD  Endocrine Research Center, Shaheed Beheshti University of Medical Sciences, Tehran, I.R. Iran, guidelines are given below.
 Recommendations during ramadan fasting
  1. Diabetic patients should continue their regular daily activity and try to more or less maintain their diet regimen as it was in the non-Ramadan days.

  1. You should know Signs of hypoglycemia (click to read)  and precautions you should take

  1. You should know Signs of diabetic ketoacidosis (click to read) also called dibetic acidosis

  1. You should know Signs of dehydration which include:

·     Dry or sticky mouth
·     Low or no urine output; concentrated urine appears dark yellow
·     Sunken eyes
·     Lethargic condition, feeling of great tiredness

  1. If you are underweight diabetic, don’t fast

  1. You should stabilize your blood sugar level and diet before Ramadan. That is you should maintain your blood sugar to normal levels and also follow a regular routine of diet with medicines.

  1. Fasting is encouraged in all overweight NIDDM patients (except for pregnant or nursing mothers) whose diabetes is stable with weight levels 20% above the ideal weight or body mass index (body weight, kg/height, meters squared) greater than 28.

  1. Studies have shown that Dietary indiscipline during the non-fasting period with excessive gorging, or increased eating, of sugar and fatty foods contribute to the tendency towards hyperglycemia and weight gain. Ramadan fasting benefits appear only in patients who maintain their appropriate diets.

  1.  It is necessary to continue their usual physical activity especially during non-fasting time of the day in Ramadan

  1. Fasting is encouraged in all overweight NIDDM patients (except for pregnant or nursing mothers) whose diabetes is stable with weight levels 20% above the ideal weight

  1. Home blood glucose monitoring should be performed just before the sunset meal and three hours afterwards. It should also be performed before the pre-dawn meal to adjust the insulin dose and prevent any hypoglycemia and post-prandial hyperglycemia following over-eating. Immediate medical help for diabetics who need medical help quickly, rather than waiting for medial assistance the next day.

  1. Further attention on fasting during the summer season and geographical areas with long fasting hours.

Remember to follow the 3Ds-
1)       Drug regimen adjustment
2)       Diet control
3)       Daily activity

For people with NIDDM (non insulin dependant) or type 2 diabetes:

If you are a NIDDM patient, you can fast after evaluating yourself based on this information:

1)       Sahur (diet before dawn) should be equal to a full meal.

2)       don’t fast on the day when you skip ‘sahur’ (diet before dawn)

3)       Drug regimens for NIDDM patients:

Available reports indicate that there are no major problems encountered with NIDDM overweight patients who observe fasting in Ramadan. With proper changes in the dosage of hypoglycemic agents there will be low risk for hypoglycemia and hyperglycemia. It is recommended that diabetics switch the morning dose (together with any mid-day dose) of this drug with the dosage taken at sunset.

For people with IDDM (insulin dependant) or type 1 diabetes:

If you are a IDDM patient, you SHOULD NOT fast. However If you decide to fast, follow this advice:

Drug regimens for IDDM patients:
Some experienced physicians conclude Ramadan fasting is safe for IDDM patients with proper self-monitoring and close professional supervision (16). It is fundamental to adjust the insulin regimen for good IDDM control during Ramadan fasting. Two insulin therapy methods have been studied successfully
    1. Three-dose insulin regimen: two doses before meals (sunset and Dawn) of short-acting insulin and one dose in the late evening of intermediate-acting insulin (16)
    2. Two-dose insulin regimen: Evening insulin combined with short-acting and medium-acting insulin equivalent to the previous morning dosage, and a pre-dawn insulin consisting only of a regular dosage of 0.1-0.2 unit/kg (25).

Fasting should not be done in these cases:
  • All brittle type I diabetic patients.
Brittle diabetes, also called labile diabetes, is a term used to describe uncontrolled type 1 diabetes. People with brittle diabetes frequently experience large swings in blood sugar (glucose) levels. These cause either hypoglycemia (low blood sugar) or hyperglycemia (high blood sugar), which is more common and sometimes extreme.

  • Poorly controlled type I or type II diabetic patients;
  • Diabetic patients known to be incompliant in terms of following advice on diet, drug regimens and daily activity;
  • Diabetic patients with serious complications such as unstable angina or uncontrolled hypertension;
  • Patients with a history of diabetic ketoacidosis;
  • Pregnant diabetic patients;
  • Diabetic patients will inter-current infections or any other added illness
  • Elderly patients with any degree of alertness problems;
  • Two or more episodes of hypoglycemia and/or hyperglycemia during Ramadan.

 You may also read:

Medication and diet Advice to the Diabetic Patient who wants to FAST during the Holy month of Ramadan:  By: Dr M Akber, Consultant Physician in Diabetes & Endocrinology
University Hospital of North Staffordshire, Stoke on Trent, UK
Ramadan and diabetes from a global diabetes community in UK