Ramadan

Ramadan is the Holy Month for Muslims, a time of worship, self-discipline, austerity and charity. During Ramadan, there are alterations to mealtimes and the daily routine, and special traditional foods are eaten.

Fasting during Ramadan has a number of physical effects on our body. In people with diabetes, these changes and the type of medication being taken to treat the condition can lead to hypoglycaemia (low blood glucose) and hyperglycaemia (high blood glucose).

The Qur’an allows you not to fast if you have an illness or medical condition. You could consider donating some money to charity as an alternative means of participating in Ramadan. But if you really want to fast, make sure you can do it safely.

If you are in any doubt about how you should manage your diabetes while you fast, you should talk to your diabetes care team. There may be circumstances when you will be advised not to fast for health reasons.

Risks to people with diabetes during Ramadan

For patients with diabetes, there are several potential risks associated with prolonged fasting including:

• Hypoglycaemia (low glucose levels), especially during the late period of fasting before iftar
• Severe hyperglycaemia (high glucose levels) after each of the main meals
• Dehydration, especially in countries with longer fasting hours and hot climates
• Significant weight gains due to increased calorie intake and reduced physical activity
• Electrolyte imbalance (minerals in the body that are involved in essential processes)
• Sudden kidney failure in patients that are prone to dehydration such as the elderly or those with reduced kidney function

Health issues during Ramadan

During Ramadan, there is a dramatic change in dietary patterns for fasting Muslims compared with other months of the year. Health issues may arise due to the change in eating habits and reduced physical activity. Unhealthy patterns that are common during Ramadan include: 

• Eating particularly large meals at iftar (consuming more than 1500 calories per meal), which may result in high blood glucose levels after eating and weight gain.
• Eating significant amounts of highly processed carbohydrates (bagels, panini) and sugar at iftar, or between iftar and suhoor, which may also cause severe high blood glucose levels.
• Eating desserts loaded with sugar after iftar, which can lead to raised blood glucose levels after meals.
• Having a lot of large snacks between the two main meals, which can contribute to longer periods of high glucose levels.
• Eating at a fast speed, which commonly leads to over-eating.
• Eating suhoor early, which may result in hypoglycaemia before iftar, especially when fasting hours are longer than usual
• Eating large portions of high glycaemic index (GI) carbohydrates at suhoor, which can lead to high blood glucose levels after meals.
• Frying food, which is particularly unhealthy, especially when using trans-fat margarine or oils rich in saturated fat (e.g. palm oil and coconut oil)
• Changes in physical activity and sleeping patterns can affect metabolism and may lead to weight gain.

Weight maintenance and weight reduction during Ramadan

Weight gain during Ramadan should be avoided. People with diabetes who are overweight or obese may find that Ramadan provides a good opportunity to lose weight. Weight loss may result in better blood glucose control and may reduce the risk of you developing problems with your heart or blood vessels. In order to achieve weight loss or avoid weight gain, the number of calories you eat should be controlled and kept within targets based on your height and gender.

Below we have set out some guidance to help you manage your diabetes during Ramadan, depending on what treatment you currently follow:

Group 1: if you manage your diabetes with diet and exercise

If you manage your diabetes with diet and exercise and don’t take any medication, as long as you continue to be careful with your diet, you can fast safely during Ramadan. If you are overweight, you may lose weight during Ramadan, which will help you improve the way you control your blood glucose levels. The following tips will be helpful:

• Divide your daily food into two meals, Sehri and Iftar.
• Have some starchy food such as cereals, basmati rice, chapatis or naan at every meal. 
• Have plenty of fruit, vegetables, dhal and yoghurt. 
• Eat only small amounts of sweet foods such as ladoo, jalebi or burfi. 
• Avoid fatty fried foods such as samosa or pakora.
• Stick to low-calorie or ‘diet’ drinks or, better still, water. Drink plenty of fluid. 

You may feel tired when fasting during Ramadan, so although it is important that you continue your daily activity and prayer, try to rest at some point in the day. Click here for a 10 Day Ramadan meal planner.

Group 2: if you manage your diabetes with diet, exercise and tablets

It is important that you follow the same guidelines as for people in Group 1 regarding diet and rest.

The advice for fasting will vary slightly depending on what diabetes medication you take. You may need to adjust your medication, depending on your symptoms and blood glucose levels. You should discuss any changes to your medication with your diabetes care team.

If you take metformin or acarbose tablets and feel unwell while you are fasting, you can consider stopping them, reducing the dose or changing the timing of when you take them. If you continue to take them, the largest dose should be taken at Iftar, so that they work when you are eating.

If you take sulphonylurea tablets or prandial glucose regulators, be aware that these can cause hypoglycaemia when you are fasting, which could make you feel ill. They should not be taken during fasting hours but you may take a dose when you are eating, e.g. at Iftar.

Pioglitazone tablets do not cause hypoglycaemia when taken alone and are usually taken once a day in the morning. If you feel unwell when you are fasting, you may wish to take them at Iftar.

DPP4 inhibitors (also known as gliptins) generally do not cause hypoglycaemia on their own. In addition, as they are taken once daily, you can continue to take them as normal, or, if it is easier, you can take them with food, e.g. at Iftar.

SGLT2 inhibitors generally do not cause hypoglycaemia on their own so you can continue to take them as normal, take a reduced dose or, if it is easier, take them with food, e.g. at Iftar.

Non-insulin injections do not cause hypoglycaemia on their own so it may be possible to continue to take these as long as you monitor your blood glucose levels closely. They can, however, cause nausea. Whether or not you can continue with these injections will depend on your blood glucose levels and symptoms.

If you are in any doubt at all about what to do with your tablets or injections when fasting, discuss it with your diabetes care team.

Testing your blood glucose when taking tablets and fasting

When you take tablets that can cause hypoglycaemia, it is a good idea to check your blood glucose more often when fasting to make sure that the level is not rising too high (more than 180 mg/dL) or dropping too low (less than 72 mg/dL).

If your results worry you and you are unsure about what to do, contact your diabetes care team for advice.

Group 3: if you manage your diabetes by taking insulin (with or without tablets)

It is important that you follow the same guidelines as for people in Group 1 regarding diet and rest.

If you manage your diabetes with insulin, it is vital that you know what to do when fasting to avoid hyperglycaemia (more than 180 mg/dL) or hypoglycaemia (less than 72 mg/dL). You must check your blood glucose frequently to make sure that it is staying within a normal range.

In general, you will need much less insulin when you are fasting and will need more during the hours when you are eating. If you do not adjust your insulin regime you will be at risk of hypoglycaemia during fasting hours.

Quick-acting insulin

Quick-acting insulins (such as Humalog and Novorapid) taken in combination with long-acting insulins provide a more flexible insulin regime, making it easier to alter the doses and change the timings of your injections. Your diabetes care team may advise you to change to a quick-acting insulin, so that you inject only when you are eating.

Intermediate and long-acting insulin

Intermediate and long-acting insulins (such as Lantus or Humulin I) are often used on their own or in combination with quick-acting insulins. The dose of long-acting insulin may need to be reduced if you are fasting.

Pre-mixed insulin

Pre-mixed insulins (such as Novomix or HumulinM3) are not usually recommended during periods of fasting. If you do continue to use these insulins, it is likely that you will have to adjust the timing and doses so that you are always taking your insulin in conjunction with eating.

You will need to discuss any changes to your insulin regime with your diabetes care team, so be sure to contact them for advice well in advance of the next Ramadan.

Some Safety Tips

• Always carry glucose treatment with you.
• Always have diabetes identification, such as a medical bracelet.
• Test your blood regularly to monitor your glucose levels. This will not break your fast.
• Test your blood glucose level if you feel unwell during the fast.
• If your blood glucose level is high or low, you must treat this.
• If your blood glucose is less than 72 mg/dL (4 mmol/L), end the fast immediately and treat the low blood glucose level.
• If your blood glucose level is 72 mg/dL (4 mmol/L) at the start of the fast and you take insulin or gliclazide, do not fast.
• If your blood glucose level is higher than 288 mg/dL (16 mmol/L), end the fast immediately. If you take insulin, you may need to take a corrective dose
• If you become dehydrated, end the fast immediately and have a drink of water.
• If you start to feel unwell, disoriented, confused, if you collapse or faint, stop fasting and have a drink of water or other fluid.
• You should never stop your insulin, but you must speak to your doctor because you may need to change the dose and times of your insulin injections.

Hypoglycaemia

If you have a hypoglycaemic episode (a ‘hypo’) while you are fasting, it is essential that you break your fast otherwise your hypoglycaemia may get worse and you could fall into a coma.

You should always be alert for the following symptoms and ask friends and family to look out for the signs too, as you may not always be aware of them yourself.

• Sweating 
• Shaking 
• Palpitations 
• Double vision 
• Hunger pangs 
• Slurred speech
• Odd behaviour 

Treatment

You should take some rapid-acting carbohydrate, such as full-fat Coke or four or five jelly sweets (be sure to check that they are halal). Then take some slow-acting carbohydrate, such as a sandwich or chapati, to keep your blood glucose levels up. Keep checking your blood glucose every ten minutes, and try to work out what caused your hypo:

• Was it because you fasted and didn't change your diabetes treatment? 
• Was it because you were doing exercise or physical activity and not resting? 

More information on hypoglycaemia and how to treat it can be found here.