Ramadan and diabetes

The month of Ramadan is a blessed month. It is one of the five pillars of Islam. It is compulsory for all healthy Muslims to fast this month. However, Allah has given exceptions for people with serious medical illnesses. Some patients with diabetes mellitus are exempt depending on the type of diabetes, complications, and medications. Nevertheless, even people who are exempt due to their health-related problem ends up fasting.

During Ramadan, people eat significant, high-fat or high-carbohydrate meals at Iftar (sunset) and Suhoor (sunrise). People without diabetes can easily cope with this change in the pattern of eating and diet. However, people with diabetes find it difficult to manage this. This is especially the case if you are taking tablets or Insulin. After eating a large meal at Iftar or Suhoor, blood sugars can go very high. During fasting, there is a significant risk of developing low blood sugar.

What should we do if we want to fast? Ramadan and diabetes

It is essential to speak to your doctor before Ramadan. It is advised to contact your doctor 6 to 8 weeks before the start of Ramadan. However, if this is not possible, then speak to your doctors as soon as possible. Your doctor will be able to let you know about your risk. This is based on guidelines and recommendations from experts.

Low Risk

People with good diabetes control below 53 mmol/mol or 7% who are treated with diet control or medication which does not cause hypoglycemia (low blood glucose) (e.g., metformin, pioglitazone, acarbose, sitagliptin, vildagliptin, linagliptin or similar, liraglutide or similar and dapagliflozin or similar) can choose to fast.

Medium Risk

People with average control of diabetes (> 7% (53 mmol/mol) but < 8% (64 mmol/mol)) can fast with caution and under advice from doctors. In addition to metformin, pioglitazone, acarbose, sitagliptin, vildagliptin, linagliptin or similar, liraglutide or similar and dapagliflozin or similar people could also be taking glucose-lowering medications like Gliclazide or glimepiride or once a day insulin.

Blood glucose should be monitored very regularly, and the dose and timing of medication need to be adjusted.

High Risk

Type 2 diabetes with poor diabetes control (between 8% (64mmol/mol) to 10% (86 mmol/mol))
Type 1 diabetes
Patients who have complications affecting their kidney
Patients taking insulin more than once per day
During pregnancy and type 2 diabetes or gestational diabetes

Very High Risk

Patients who fall into this group must not fast. This group includes people who have:

Recent hospital admission due to diabetes like severe high blood glucose (diabetic ketoacidosis, hyperosmolar hyperglycemia or severe hypoglycemia).
People who cannot feel their low blood glucose
People who suffer from repeated low blood glucose
People with very poor diabetes control (HbA1c > 10% (86 mmol/mol))
People who have severe diabetes-related complications like having dialysis
Old age or illness

If people in high-risk or very high-risk groups end up fasting, then they should check their blood glucose more often and be willing to have breakfast if blood glucose is not controlled.

When should fast be broken?

Fast should be broken if blood glucose is very low (< 70 mg/dl or 3.9 mmol/L) or high (> 300mg/dl or 16.6 mmol/L).

How often blood glucose should be tested?

Blood glucose should be tested as often as needed. Blood glucose should be tested if a person feels unwell or develop symptoms of hypoglycemia (low blood glucose) or hyperglycemia (high blood glucose).

Blood glucose should be checked before iftar and suhoor, 2-3 hours after iftar and suhoor and halfway through fast.

What is the risk during fasting?

People with diabetes can suffer three main problems

Hypoglycemia (Low Blood glucose – <4 mmol/l or 70 mg/dl)
Hyperglycemia (High Blood Glucose – 16.6 mmol/l or 300mg/dl)
Dehydration

What is the meaning of hypoglycemia or low blood glucose?

Blood glucose below 4 mmol/L is low blood glucose or hypoglycemia. If blood glucose is below 4 mmol/L, then fast should be broken.

How should a person feel when blood glucose goes below 4 mmol/L (70 mg/dl)?

The person will feel unwell and can experience the following:

Shaky
Sweating
Cold
Palpitations (feeling heart beating fast)
Hunger
Headache
Unable to concentrate
Blurred vision

In severe cases, a person can become confused or lose consciousness or develop a seizure. Family and friends should be informed to look out for these symptoms in the person with diabetes. They should help in treating you, or if you are unconscious, then call the ambulance.

How should low blood glucose be treated?

Once it is confirmed that blood glucose is low then fast should and must be broken immediately. Following things can be used:

150-200 ml of pure fruit juice or
Glucose tablet (4-6) or
4-5 Jelly babies

A small snack should also be taken. Blood glucose should be retested in 15 minutes. If blood glucose is still below 4 mmol/L or 70 mg/dl, then the above treatment must be repeated.

How should I feel if my blood glucose is high?

Blood glucose above 16.6 mmol/L or 300mg/dl is termed high. In this case, it is advised that fast should and must be broken.

A person will be extremely tired, thirsty and passing lots of urine. This can lead to dehydration. If high blood glucose levels persist, then this can lead to hospitalization and life-threatening condition.

How to avoid high blood glucose?

The best way to control blood glucose is to take medication as per advised by the doctor.

Drink plenty of fluid/liquid between Iftar and suhoor.
Avoid or limit food with high glucose or fat.

How will I feel if I become dehydrated?

A person can feel dizzy, have blurred vision and become confused. In severe cases, a person can lose consciousness.

How to avoid dehydration?

Drink plenty of sugar-free fluid between Iftar and Sahoor. Avid or limit food and fluid with high sugar content.

How should oral medications for diabetes be adjusted?

It is important to speak to your doctor before making any changes in medication. Below, we present some of general guidance:

If medication is taken once a day, then it is advised to take the medication with Iftar.

If the medication is taken twice a day, then it should be taken at Iftar and Sahoor.
In most cases, the dose of Metformin, pioglitazone, acarbose, sitagliptin or similar and Liraglutide or similar.
Dapagliflozin or similar can cause dehydration and should be taken only on the advice of the doctor. However, the dose does not need any dose adjustment.
Sulfonylurea can cause hypoglycemia. However, if sulfonylurea is not taken, then blood glucose can also go very high. The dose will need to adjust and should be done with the advice of the doctor. If the blood glucose is well controlled then, then the dose of the tablets can be reduced to 75% of the total dose. The morning dose should be taken with Iftar.

How should Insulin adjusted during Ramadan?

Insulin can cause hypoglycemia. However, if Insulin is not taken, then blood glucose can also go very high. The dose will need to adjust and should be done with the advice of the doctor. If blood glucose is well controlled, then the dose can be reduced to 75% of the total dose. A higher or full dose is taken at Iftar.