Fasting (Sawn or Roza) during the holy month of Ramadan is one of the five pillars of Islam and commemorates the time when the Holy Quran was revealed to Prophet Muhhammad (PBUH). The month-long (29-30 day) fast is obligatory for all healthy Muslims who have reached puberty. Followers must refrain from eating and drinking between dawn and sunset, and must abstain from using oral medications, sexual activity and smoking.
Ramadan is widely observed across the world. Followers must refrain from eating and drinking between dawn (suhoor) and sunset (iftar), and must also abstain from using oral medications, sexual activity and smoking.
Fasting is mandatory for all Muslim adults, with certain groups exempted. These include:
People with an illness
Women who are pregnant, breastfeeding or menstruating
Many Muslims, even those who could seek exemption, have an intense desire to participate in fasting during Ramadan.
Due to the metabolic nature of the condition, people with diabetes are at particular risk of complications from marked changes in food and fluid intake. Potential complications include:
Low blood glucose (hypoglycaemia)
High blood glucose (hyperglycaemia)
Diabetic ketoacidosis (DKA), in people with type 1 diabetes
Estimates suggest that there are over 150 million Muslims with diabetes worldwide. Despite being exempt, many people with diabetes participate in fasting during Ramadan. Therefore, Ramadan has a major impact on the management of diabetes in the Muslim population.
Fasting and diabetes
It is important that the decision about whether to fast is made on an individual basis in consultation with a healthcare provider, taking into account the severity of illness and the level of risk involved. A cornerstone of managing diabetes during Ramadan is patient education, which should include information on risks, glucose monitoring, nutrition, exercise and medication.
Studies have shown that pre-Ramadan counselling reduces the episodes of low blood glucose. Pre-Ramadan education provides a platform to remind people with diabetes about the importance of diet and exercise, and that regular glucose monitoring is essential to avoid complications, while reassuring them that this does not invalidate the fast.
Update concerning COVID-19:
The currently available epidemiological data shows that people who fast do not report higher rates of infections or hospitalization. There is therefore no evidence that fasting could lead to reduced immunity and higher risk for infection.
However, people with diabetes and complications, such as renal impairment or foot problems, are at high risker of infections. It is therefore important that they follow medical advice and do not fast to avoid increasing their risk of contracting COVID-19.
Tips for a healthy Ramadan with diabetes
Know your risk before you decide to fast
As per the Holy Quran, there are groups of people who might make themselves ill by fasting. Based on medical and religious advice, it is recommended to visit your doctor 6-8 weeks before Ramadan to understand your risk category before deciding to fast. If your doctor advises not to fast, you will get the same Thawab (reward).
Check your blood glucose regularly
Blood glucose monitoring and insulin injections do not break the fast and are important. They are your window to know your blood glucose levels and manage your diabetes. Changes in eating habits during Ramadan may affect your blood glucose and therefore it is important check blood glucose levels regularly.
People at very high risk (even if not fasting) should check blood glucose levels 3-4 times a day
People at moderate or low risk should check blood glucose levels 1-2 times a day
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.
It is important to know that measuring your blood glucose and injecting insulin will not break your fast.
When to break the fast?
All people with diabetes should break the fast if:
Blood glucose is lower than 70 mg/dl (3.9 m mol/L). Re-check within one hour if blood glucose is in the range 70-90 mg/dl (50- 3.9 m mol/L)
Blood glucose is higher than 300 mg/dl (16.6 m mol/L)*
Symptoms of hypoglycemia, hyperglycemia, dehydration or acute illness occur
Exercising during Ramadan
Perform regular light-to moderate exercise. Rigorous exercise is not recommended during fasting because of the increased risk of low blood glucose and/or dehydration. Physical exertions involved in Tarawih prayers, such as bowing, kneeling and rising, should be considered part of your daily exercise activities.
When the month of Ramadan ends
Avoid over-eating (especially sweets) during Eid-ul-Fitr, as it may lead to high blood glucose. Visit your doctor to obtain guidance on changing the medication back to the previous schedule.
Dietary advice for people with diabetes during fasting
Divide daily calories between Suhoor and Iftar, plus 1-2 snacks if necessary
Ensure meals are well balanced: 45-50% carbohydrate 20-30% protein <35% fat
Include plenty of fruit, vegetables and salads
Minimise foods that are high in saturated fats (ghee, samosas, pakoras)
Use small amounts of oil when cooking (olive, rapeseed)
Stay hydrated at or between the two main meals by drinking water or other non-sweetened beverages. Avoid caffeinated, sweetened drinks and sugary desserts
Include low glycaemic index, high fibre foods that release energy slowly before and after fasting (granary bread, beans, rice)
IDF-DAR Practical Guidelines
With the global prevalence of diabetes continuing to increase, and the number of fasting Muslims set to rise, the importance of effective guidelines for the management of diabetes during Ramadan fasting is clear. The IDF-DAR Practical Guidelines provide healthcare professionals with both background and practical information, as well as management recommendations to optimise the care delivered to people with diabetes who plan to fast during Ramadan.