How to Manage Diabetes during Ramadan Fasting : 55 FAQs

Dr. Om J. Lakhani
MBBS, MD, DNB (Endo), Specialty Certificate in Endocrinology from RCP, UK

Ramadan is an important month for Muslims all over the world. Since Ramadan requires prolonged day time fasting, it produces changes in the metabolic milieu of the human body.

As you can imagine, it can have a significant impact on a metabolic disease like Diabetes mellitus. In this article we have answered some frequently asked questions regarding diabetes mellitus and Ramadan.

Frequently Asked Questions On Diabetes Mellitus And Ramadan

How long is the fast period during Ramadan?
About 1 month
What are the restrictions suggested?

Avoid eating, oral medication, drinking, smoking, and sexual activity from dawn to sunset.

Who is exempted from fasting?
  • Elderly
  • Children
  • Pregnant women: (a) Pregnant women are told to fast for a similar period after delivery and (b) Those who cannot fast are asked to donate to the poor for every day of missed fast
How long during the day the fast lasts?

Since Ramadan is based on the Lunar calendar, it starts 10-11 day earlier each time. Hence the fasting may last longer in Summer times

Are patients with Diabetes exempt from fast?

Yes. Yet they fast for 15 days at least.

What is Shawwal?

1 month following Eid.

What aspects of the human body are affected during the fasting in Ramadan?
  • Meal times change
  • Water and fluid intake reduces
  • Sleep changes occurs
  • Changes in physical activity
What are the typical meal times in Ramadan?

6:00 pm and 3:00 am

What is Suhoor?

Muslims wake up before dawn to eat before the fast begins. This is called Suhoor. Many go back to sleep and wake up later again.

What is Iftar?

Evening meal after sunset. The largest calorie intake is during Iftar.

What is the impact of sleep on Diabetes in Ramadan?

Sleep disturbance is well known to increase insulin resistance. There is noticed sleep disturbance in Ramadan.

What happens to hunger?

During the initial days, the hunger is increased, while during the later days of fast, there is adaptation- particularly in females.

What happens to the body weight during Ramadan?

There are conflicting reports.

Current evidence suggests that body weight reduces or remains the same during Ramadan.

Males typically lose weight, while women maintain weight.

Does this lead to changes in Fasting blood glucose in people with Diabetes?

Interestingly No! There is little change in Glucose levels observed in CGMS in diabetics. There is a mild increase after Iftar noted.

What happens to lipid profile during Ramadan?
  • During Ramadan, there is an observed reduction in LDL
  • There is a favorable lipid profile during Ramadan months
What is the potential risk for people with Diabetes during Ramadan?

Increase risk of

  • Hypoglycemia (low sugars)
  • Ketoacidosis
  • Hyperglycemia (high sugars)
  • Dehydration
  • Thrombosis (Clot formation)
What is the risk of hypoglycemia (low sugar)?
  • 4-7 times increase risk of severe low sugar in type 1 and type 2 diabetics
  • There are also 3-5 times increase risk of hyperglycemia (high sugar)
What is the result of dehydration in people with Diabetes?

Dehydration in people with Diabetes during Ramadan increases the risk of retinal vein block, which is found to increase during Ramadan months

Risk stratification of Diabetes in Ramadan

What is the risk stratification for people with Diabetes in Ramadan as suggested by international bodies?

Four groups according to American diabetes association guidelines

  • Very high risk
  • High risk
  • Moderate risk
  • Low risk

These risk group are endorsed by Islamic religious leaders as well

Who is in category 1 – very high risk?

Very high risk group includes

  • Severe hypoglycemia (low sugar) in last 3 months
  • Hyperglycemic hyperosmolar state (a critical form of severely high sugar) in the last 3 months
  • Diabetic ketoacidosis in last 3 months
  • Pregnant with diabetes / GDM on Insulin/ SU
  • Poorly controlled type 1 diabetes
  • Hypoglycemic unawareness (not aware of sugars going low)
  • Severe macrovascular disease (heart disease and stroke)
  • Old age
  • Acute illness
  • Kidney failure on dialysis
  • This group are EXEMPT FROM FAST
What are high-risk groups?

High risk group includes:

  • Poorly controlled type 2
  • Type 2 diabetes on Insulin (twice a day or multiple doses)
  • Well-controlled type 1 diabetes patients
  • Diabetes in pregnancy on metformin/diet control
  • Stable macrovascular disease
  • CKD stage 3
  • Those doing intense physical labor
Who is at low/moderate risk?

Type 2 diabetics on oral medications / basal insulin alone (once a day insulin)

Who is exempt from fast?
  • Very high risk and high risk are exempt
  • Low and moderate risk can fast
Are type 1 diabetes patients exempt from fasting?
  • Type 1 diabetes fall in high or very high risk and are always exempt from fast
  • Young type 1 otherwise well may fast- however, they must be educated well
  • Regular glucose monitoring during fast is vital

Pre-Ramadan education

What are the key components of Ramadan medical education?
  • Risk stratification
  • Blood glucose monitoring
  • Fluid and diet advice
  • Exercise advice
  • Medication adjustment
  • When to break the fast
When should the risk stratification be done?

It must be done 6-8 weeks before Ramadan

Is blood glucose monitoring with glucometer a violation of Ramadan rules?

No. This is a misconception. Blood glucose monitoring is allowed during Ramadan.

Which particular time is blood glucose monitoring particularly required?

After iftar (post-prandial)

Please give some dietary advice during Ramadan?
  • Divide daily calories between suhoor and iftar, plus 1-2 snacks if necessary
  • Ensure meals are well balanced
    • 45-50% carbohydrate
    • 20-30% protein
    • less than 35% fat (preferably mono- and polyunsaturated)
  • Include low glycemic index, high fiber foods that release energy slowly before and after fasting E.g. granary bread, beans, rice
  • Include plenty of fruit, vegetables and salads
  • Minimise foods that are high in saturated fats E.g. ghee, samosas, pakoras
  • Avoid sugary desserts
  • Use small amounts of oil when cooking E.g. olive, rapeseed
  • Keep hydrated between sunset and sunrise by drinking water or other non-sweetened beverages
  • Avoid caffeinated and sweetened drinks
What about exercise?
  • Rigorous exercise is not encouraged
  • Regular light to moderate exercise during Ramadan is encouraged
When should the fast be broken?

It is you develop low sugar, you must break the fast

Nutrition during Ramadan

nutrition during ramadan

Please give some other practical advice on nutrition during Ramadan?
  • Avoid excess calories in Iftaar
  • Avoid frequent snack between meals
  • Avoid early Suhoor, which can cause hypoglycemia before Iftar
  • Proper hydration
  • Avoid sweetened beverages
  • Control on desserts and sweets
  • Consumption of low GI index food
  • Avoid fried food
  • Divide calories equally between Suhoor and Iftar
What are caloric targets for people with Diabetes during Ramadan?
Weight maintenance Weight loss
Men 1800 – 2200 1800
Women > 150cm height 1500 – 1900 1500
Women < 150cm height 1500 1200
What should be the percentage of caloric distribution?
  • Suhoor – 30-40% of calories
  • Iftar- 40-50% of calories
  • Snack – 10-20% of calories
What should be the meal composition of Suhoor?
  • Good protein and fat content
  • More fiber content
  • All this will help to kill hunger and avoid hypoglycemia

Describe the ‘Ramdan plate’?

ramadan plate

When should planning for Ramadan management start?

Pre-Ramadan assessment must be done 6-8 weeks before Ramadan. This includes:

  • Medical evaluation and evaluation of Diabetes status
  • Risk categorization and advice for fast
  • Education
  • Dietary advice
  • Medication advice during Ramadan
How frequently to perform self-glucose monitoring?
  • Low /moderate risk- 1-2 times a day
  • High / very high risk- avoid fast, if done, then check several times a day
What are changes recommended for Metformin?

Metformin can be continued during fasting. Timing needs to be adjusted:

  • Once a day – take during Iftaar
  • long-acting preparation- take during Iftar
  • Twice a day – take at Suhoor and Iftar
  • Thrice a day – combine two doses and give at Iftar and one at Suhoor
What is the guidance on Use of Sulphonylureas?
  • Glibenclamide – avoid
  • Glimiperide , Gliclazide and glipizide may be used
What is the recommendation for SGLT2 inhibitors?

Remember there is additionally the risk of dehydration and ketosis in Ramdan

  • It can be used in Ramdan but use with caution
  • If used given at Iftar and you must take more fluid during the nighttime
Overall, what is the take on the use of DPP-IV is Ramadan?
  • They are safe and effective with a low risk of hypoglycemia
  • They are ideal drugs during Ramadan
  • They do not require any modifications during Ramadan
What about GLP1 analogs?
  • Liraglutide is a safe and practical add on to Metformin amongst Ramadan patients
  • It does not require any dose modification

Insulin treatment during Ramadan

Is Basal insulin glargine safe in Ramadan ?


What is a good strategy for Ramadan patients with premixed insulin?
  • Give insulin 50/50 at Iftar and insulin 30/70 at Suhoor
  • This is better than twice daily premixed 30/70
Give the guidelines for basal insulin use in Ramadan?
  • Once a day basal insulin- reduce dose by 15-30% and take it at Iftar
  • For twice a day basal insulin – take the morning dose with iftar and evening dose with Suhoor and reduce the Suhoor dose by 50%
What about short-acting insulin?
  • Omit lunch-time dose
  • Take the usual dose at Iftar and adjust as required
  • Reduce amount by 25-50% at Suhoor
What about Premixed insulin?
  • Once a day – take the same dose but at Iftar
  • Twice a day- reduce the Suhoor dose by 25-50%
  • Thrice a day – switch to twice a day and adjust doses at Iftar and Suhoor

Management of type 1 diabetes during Ramadan

Does the risk of Diabetic ketoacidosis (DKA) risk increase during Ramadan?


When should patients with type 1 diabetes they break their fast?

Blood glucose <70 mg/dl or >300mg/dl

What are the self glucose monitoring guidelines for a patient type 1 diabetes during Ramadan?

Check Blood glucose during the following time:

  • Pre-suhoor
  • Morning
  • Midday
  • Mid-afternoon
  • Before Iftar
  • 2 hours post Iftar

Any time there is a feeling of low sugar or unwell

What adjustments are advised for patients with type 1 diabetes who insist on fasting?
  • Basal-bolus would be ideal
  • Reduce the basal dose by 30%
  • Skip the afternoon short-acting
  • Reduce suhoor dose by 30%
  • Normal dose at Iftar
What about the use of insulin pumps?
  • They can be used during Ramadan
  • However, they will need appropriate adjustments
  • Reduce basal rate by 30% in last few hours of fast during the day and increase by 30% after Iftar
  • Keep Insulin sensitivity factor and Insulin carb ratio the same

Pregnancy, Diabetes, and Ramadan

What are the general recommendations for pregnant women with diabetes during Ramadan?
  • Pregnant women should not fast
  • However, Muslim laws insist they must compensate at a later date
  • However, they will have to fast alone, which is more difficult
  • Hence many chose to fast during Ramadan despite against medical advice
  • If they have diabetes, they are Very high risk
What are the potential problems of fasting during pregnancy?
  • Learning disabilities in the fetus
  • The lower weight of the of placenta
  • Poor growth
  • Long term adverse programming of the fetus
  • Lower birth weight

Post Ramadan

What is done during the Post Ramadan period?
  • Avoid overindulgence during Eid
  • Schedule a visit with Healthcare provider after Ramadan is over