How to Manage Diabetes during Ramadan Fasting : 55 FAQs

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

• 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

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

Yes. Yet they fast for 15 days at least.

1 month following Eid.

• Meal times change
• Water and fluid intake reduces
• Sleep changes occurs
• Changes in physical activity

6:00 pm and 3:00 am

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.

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

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

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

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.

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

• During Ramadan, there is an observed reduction in LDL
• There is a favorable lipid profile during Ramadan months

Increase risk of

• Hypoglycemia (low sugars)
• Ketoacidosis
• Hyperglycemia (high sugars)
• Dehydration
• Thrombosis (Clot formation)

• 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)

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

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

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

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

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

• Very high risk and high risk are exempt
• Low and moderate risk can fast

• 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

• Risk stratification
• Blood glucose monitoring
• Fluid and diet advice
• Exercise advice
• Medication adjustment
• When to break the fast

It must be done 6-8 weeks before Ramadan

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

After iftar (post-prandial)

• 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

• Rigorous exercise is not encouraged
• Regular light to moderate exercise during Ramadan is encouraged

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

• 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

• Suhoor – 30-40% of calories
• Iftar- 40-50% of calories
• Snack – 10-20% of calories

• Good protein and fat content
• More fiber content
• All this will help to kill hunger and avoid hypoglycemia

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

• Low /moderate risk- 1-2 times a day
• High / very high risk- avoid fast, if done, then check several times a day

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

• Glibenclamide – avoid
• Glimiperide , Gliclazide and glipizide may be used

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

• 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

• Liraglutide is a safe and practical add on to Metformin amongst Ramadan patients
• It does not require any dose modification

Yes

• Give insulin 50/50 at Iftar and insulin 30/70 at Suhoor
• This is better than twice daily premixed 30/70

• 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%

• Omit lunch-time dose
• Take the usual dose at Iftar and adjust as required
• Reduce amount by 25-50% at Suhoor

• 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

Yes

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

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

• 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

• 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

• 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

• Learning disabilities in the fetus
• The lower weight of the of placenta
• Poor growth
• Long term adverse programming of the fetus
• Lower birth weight

• Avoid overindulgence during Eid
• Schedule a visit with Healthcare provider after Ramadan is over