Ramadan is the name of the ninth month in the Islamic calendar. Because timing of Ramadan is based on the lunar calendar, it starts on a different day each year.
During the month of Ramadan, followers of Islamic tradition engage in a daily fast. The yearly event is observed as a time to focus on prayer, purification (hence the fast), and charitable acts.
The fast is supposed to last from dawn to dusk, so followers can eat before and after the daytime fast. Depending on geographic location, the fast can last from several days to the full 30 days. But what if you have diabetes? Can you safely manage the fast?
The daily fast requires abstaining from all food, drink, oral medications, and smoking. Muslims typically wake up early enough to pray and eat before the day’s fast begins, and a second meal is consumed after dusk. All adults deemed fit and healthy are expected to follow the thirty-day fast, while children and the elderly are exempt.
Fasting is not supposed to create excessive hardship, and the Koran makes reference to exempting the very ill from this responsibility, especially if the fasting will result in harm. Having diabetes is one such condition that would exempt you from the yearly fast. Despite the exemption, however, many individuals still commit to the fast, which poses challenges for them and their doctors.
Because little data existed regarding multi-day fasts like Ramadan, an article published in 2005 shared the consensus of several endocrinologists who gathered to discuss the safety issues and guidelines necessary to help individuals with diabetes.
An individual with Type 1 diabetes who is poorly controlled would be most at risk. The risks are specifically related to health complications from blood sugar and insulin level fluctuations, the result of no food for many hours. These individuals in particular — though all people with diabetes — increase their risk of hypoglycemia, diabetic ketoacidosis, severe negative consequences from dehydration, and thrombosis.
A 2010 update of the 2005 article recommended:
- An individualized plan for each person to manage anticipated issues based on their risk profile
- Frequent monitoring of blood glucose levels
- Avoiding the ingestion of large amounts of carbohydrates or fats when eating the two peripheral meals
- Avoiding moderate or vigorous exercise and staying cognizant of blood sugar levels during the “rising, kneeling, bowing moments of prayer”
- Avoiding fasts on any sick days
- Breaking the fast if blood sugar falls below 60 milligrams per deciliter
In 2016, the International Diabetes Federation (IDF) and The Diabetes and Ramadan (DAR) International Alliance created a set of practical guidelines for people with diabetes who want to participate in the fast of Ramadan. The extensive paper offers assessment strategies to help determine who can safely fast, guidelines for monitoring blood sugar levels during the daily fast, and a nutritionally balanced menu outline for the two daily meals. Strategies for medication management are also offered in this nine-chapter, comprehensive document.
The Joslin Diabetes Center also offers a Ramadan fasting guide for people with diabetes (there’s also a version in Arabic), as well as a separate guide for physicians treating patients with diabetes who want to follow the fasting custom.
The guidelines emphasize the Koran’s teachings that people with health risks should refrain from fasting. Thus, people with poorly controlled diabetes, individuals using insulin, patients with mixed type diabetes, and patients who struggle with high and low blood sugar stabilization problems do not have to follow the fast of Ramadan.
The guidelines also emphasize that checking your blood sugar during the fasting hours does not "break the fast." The guidelines provide recommendations for treating low blood sugar, as well as meal guidelines.
Both sets of guidelines mentioned in this article highlight that the meals are not supposed to be celebratory in nature, so following standard meal-planning guidelines for a diabetes-friendly diet is a given. The guidelines also caution against exercise or vigorous activity during fasting periods.
A study published in Diabetes Technology and Therapeutics (DTT) compared patients with Type 1 diabetes who used an insulin pump during Ramadan fasts to individuals who used traditional insulin injections. The researchers wanted to see whether one was more beneficial than the other with respect to blood sugar control and negative outcomes.
Between the two methods, they found little difference in risk of mild hypoglycemia or even severe hypoglycemia. What they did find, however, was that the continuous infusion supported less blood glucose variability overall. They also assumed that use of an artificial pancreas hybrid closed loop system would further protect against periods of hypoglycemia and allow for better blood sugar control.
Experts emphasize that, even if you know someone with diabetes who has successfully followed the Ramadan fast, it does not necessarily mean that you can. Always check with your diabetes team before embarking on such a fast.
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