Adjusting Insulin Regimes in Relation to Food and Religious Holidays
Our diabetes team is often asked about adjusting insulin regimes in relation to food and religious holidays. Typically, most religious holidays involve celebrations with ethnic foods, which is often a major challenge when it comes to counting carbohydrates and manipulating insulin regimens. In these situations, additional blood glucose monitoring and extra bolus and correction insulin usually solves these problems. Perhaps the most difficult situations arise, however, with the fasting holidays such as Ramadan and Yom Kippur. How does one manage the different insulin regimes to adapt to fasting holidays? Keep in mind that most religious leaders will give permission to break a fast if the observer's health is in question. (Lows must be treated with some form of oral rapid acting carbohydrate.)
Planning is essential prior to the holidays and blood glucose levels should be monitored closely. Ramadan poses special problems due to the 30-day celebration in which fasting occurs throughout daylight hours with a meal consumed before dawn and after sundown. The key in this situation is to avoid hypoglycemia as best as possible. Insulin strategies depend on the regime employed. Basal/bolus therapy, including both multiple dose injections of basal insulin (lantus or levemir) and bolus insulin (novolog, humalog or apidra) allows for flexibility, which is extremely beneficial when trying to fast and keep blood sugars in an acceptable range. On the other hand, it is more challenging when trying to adapt a split-mixed insulin regimen (2 or 3 shots per day) to include fasting throughout part or most of the day. (We are often faced with these issues of fasting when our children or teens with diabetes require surgery and must be NPO <nothing per os -mouth>). Below are suggestions that may be applicable on fasting holidays based on type of insulin regimen.
1. Split-mixed insulin regime: 2 or 3 shots per day. If the fast occurs throughout most of the day, such as in Ramadan (with meals served before dawn and after sundown) and Yom Kippur (with a meal served after sundown), give usual evening NPH at either the evening meal or at bedtime (depending on your 2 or 3 shot regimen). It is possible that the NPH may need to be decreased to avoid lows overnight or in the morning (check blood sugar around 3 am). On the morning of the fast (Ramadan), we would suggest giving 1/2 of the usual morning NPH and your usual rapid acting bolus insulin to cover the predawn meal. (If the bolus insulin is regular, consider decreasing by 1/3 to ½ the usual amount). If observing Yom Kippur, give ½ of your usual morning NPH and NO bolus insulin (regular or rapid-acting analog). In this way, the NPH will act to cover the stored glucose released naturally by the liver to provide the necessary energy to go about daily activities. Now is not the time to obtain energy by breaking down fat due to the potential development of ketones. However, frequent blood glucose monitoring is essential to detect either highs or lows. No further insulin should be required throughout the day unless hyperglycemia occurs. (Discuss insulin correction amounts with your diabetes team in advance.) For the evening (after sunset) meal one would give their usual bolus of either regular or rapid acting insulin. Provide dinner or bedtime NPH as usual.
2. Multiple daily injections of rapid acting insulin and basal insulin (lantus or levemir): Give usual evening basal insulin (lantus or levemir). Once again, it is possible the basal insulin may need to be decreased to avoid lows in the morning. Bolus rapid acting insulin for the predawn meal (Ramadan). There is no need for bolus insulin throughout the day unless blood sugars are high and need to be corrected. Blood glucose monitoring is essential throughout the day. Lows must be treated with oral rapid acting carbohydrate. At the conclusion of the fast, go ahead and provide the appropriate rapid acting bolus insulin for the evening meal. Give basal insulin at bedtime as usual.
3. Insulin pump therapy: Continue usual basal rates throughout the day. This may be the best time to perform "basal rate checks" as you will not be eating voluntarily! It may be necessary to run a temporary basal rate throughout the day (decrease by 10 to 20%) to avoid lows. Check blood sugars frequently to determine the need for basal rate changes. For either the predawn or evening meals, bolus for carbohydrates (or correction) as usual.
Keep in mind that if your child/teen feels dizzy, weak or ill, blood sugars need to be checked. Your child's safety should be most important and most religious leaders (if not all, would support this statement). I would suggest a meeting with your religious advisor/leader prior to the holiday to allay any fears or concerns prior to the potential fasting. A discussion with your diabetes team to strategize also would be appropriate. As always, planning ahead should allow you and your child/teen with diabetes to participate in all secular and religious events.