Diabetes and Ramadan

Ramadan is a sacred month for Muslims, and healthy adolescent and adult Muslims are required to fast from dawn to sunset at this time. This can cause problems for some people with diabetes, but most can fast with good medical advice and management.

Fasting during Ramadan is one of the five pillars of Islam, and all healthy adolescent and adult Muslims are obliged to refrain from eating and drinking from dawn to sunset during this lunar month. The fast may last 11–20 hours, depending on where and at what time of year Ramadan occurs.

People with long-term conditions such as diabetes are not obliged to fast, however, many still choose to fast. Most people with type 2 diabetes can fast safely with appropriate medical advice and management before and during fasting. However, people with type 1 diabetes need special attention, and pregnant women with diabetes are advised not to fast.

What are the safety concerns of fasting if you have diabetes?

Low blood glucose (hypoglycaemia)

For people with diabetes taking sulfonylureas (eg, glipizide or gliclazide tablets) or insulin, fasting carries the risk of low blood glucose (hypoglycaemia or hypo). All other medications can be continued, but the timing of your doses may change. If not treated quickly, hypoglycaemia can cause you to become unconscious. If you feel that you are having a hypo, you must break your fast and take some sugary fluids followed by starchy food as otherwise you will harm your body and may need medical attention.

High blood glucose and diabetic ketoacidosis (DKA)

You may develop high blood glucose levels during a fast if you do not take prescribed medication, or if you are less physically active than normal. This could lead to diabetic ketoacidosis (DKA) – a serious condition requiring hospital treatment.

Other complications

If you have complications associated with diabetes, such as poor vision or heart or kidney disease, the risk of making these worse is very high and you should seriously consider not fasting. Read more about diabetes complications.

Tips for safe fasting

During Ramadan your regular eating pattern changes, due to long gaps between meals and feasting after iftar. This can lead to greater swings in your blood glucose levels.

  • Talk to your healthcare provider about your risk. Not all people with diabetes have the same risk of low blood glucose and other complications. Depending on your risk, your healthcare provider will work with you to develop a plan for how to manage your diabetes during Ramadan.
  • Continue maintaining a healthy diet. Proper nutrition is important to prevent health problems and so eating during Ramadan should not be much different from healthy eating during the rest of the year. It is normal to feel hungry 2 hours after iftar, but you should avoid overeating traditional sweets and should choose healthier snack options such as 100-200g low fat yoghurt, 1-2 pieces of fruit, a cup of low fat milk, a wholegrain salad-and-cheese or tuna-and-salad sandwich, a handful of (unsalted) nuts, or some hummus dip with vegetable sticks.
  • Check your blood glucose levels more frequently. You may be asked to monitor your blood glucose at home, using a glucometer. If you are taking insulin or sulfonylureas (eg, glipizide or gliclazide tablets), you may be asked to do this more frequently than usual. Read more about blood glucose testing at home for type 2 diabetes. 
  • Be prepared to break your fast in case of low blood glucose (hypoglycaemia). You can break your fast with the tradition of dates, water and a bowl of soup, as these will provide an instant energy boost and hydration, to help settle hunger and prevent overeating at the main meal. It is recommended to only have 3 dates (which equal 1 carbohydrate exchange).
  • Keep yourself well hydrated. Fluid intake is important to prevent dehydration. You should aim to drink 2 cups of water each hour past sunset and aim to drink two and a half litres of fluid by suhoor. 
  • Continue to do regular, light exercise. Avoid over exercising and intense physical activity while fasting. This can lead to hypoglycaemia and dehydration. See below – can I exercise during during Ramadan.

How do I manage my diabetes medicines during fasting?

Insulin or sulfonylureas (eg, glipizide or gliclazide tablets)

If you are taking sulfonylureas (eg, glipizide or gliclazide tablets) or insulin and wish to fast during Ramadan, speak to your healthcare provider.

  • You may be asked to monitor your blood glucose at home, using a glucometer, and may need to adjust your doses based on the glucose goals you have discussed before starting Ramadan.
  • They may ask you to have tests to check your kidney and liver, as having kidney and liver problems increases your risk of hypoglycaemia.
  • Your healthcare provider will give you specific advice depending on the type of insulin you are taking. Pre-mixed insulin is not recommended during fasting.
  • If you lose weight due to fasting, you may need a reduction in your basal insulin dose in the second half of Ramadan.

Empagliflozin 

Fasting may increase the risk of diabetic ketoacidosis (DKA) if you are taking empagliflozin, but studies have shown no increased risk of DKA in people who still have a normal total daily carbohydrate intake (e.g. > 130 g carbohydrate/day). So, if you are still getting enough carbohydrates while fasting, you can continue taking empagliflozin during Ramadan. If your daily intake of carbohydrates reduces or if you feel unwell while taking empagliflozin, contact your doctor immediately. Read more about empagliflozin.

Can I exercise during Ramadan?

You can do regular and light exercise during Ramadan, as exercise is an important part of your diabetes treatment. However, you should take care to avoid low blood glucose (hypoglycaemia) and dehydration. This is particularly important when Ramadan falls in summer months, both due to the higher temperature and the greater number of daylight hours. You should try to divide your daily calories between the breakfast (suhoor) meal and the iftar meal. Try to eat well-balanced, low–glycaemic-index foods that are high in fibre, such as fruits and vegetables. Avoid over exercising and intense physical activity while fasting.

References

  1. Diabetes and Ramadan – a medico-religious perspective NZSSD
Credits: Sandra Ponen, pharmacist. Reviewed By: Dr Ryan Paul, Endocrinologist, Hamilton Last reviewed: 07 Dec 2021