Diabetes and Ramadan: Frequently asked questions

Introduction:

Fasting during the holy month of Ramadhan is ordained for all healthy Muslim adults. People who are exempted includes children, pregnant or breastfeeding women, the elderly and anyone who might get themselves ill by fasting. Often people ask whether a diabetic patient can observe fasting. In fact, most of them can observe fasting safely during Ramadhan, No wonder about 80 percent of 120 million Muslims with diabetes all over the world undertake fasting during Ramadhan.

What happens to sugars during Fasting: During a fast, at about eight hours after your last meal, your body starts to use energy stores to keep your blood glucose (sugar) levels normal. For most people this is not harmful, but if you have diabetes, your body cannot use the glucose as well as it should. With diabetes – especially if you take certain tablets or insulin – you are at risk of hypoglycemia (low blood glucose levels). Ramadhan fasting not only alters the timings of meals but it may also disturb sleeping patterns and hormonal rhythms, all of which can affect a person’s metabolic state.

What are the benefits of fasting: Fasting during Ramadhan can also be beneficial. It may provide an opportunity to reduce caloric intake, facilitate weight loss, and smoking cessation. It may help to strengthen the therapeutic alliance between patient and physician, and provide an opportunity to improve diabetes management, with a focus on self-care and the regulation of medication and meal timing.

What are the challenges of Fasting: In people with complicated diabetes it may cause hypoglycemia (decrease in blood glucose level), hyperglycemia (increase in blood glucose levels), dehydration and diabetes ketoacidosis. During fasting time, patients may suffer from hypoglycemia due to lack of glucose while after evening people might encounter increased glucose levels due to excessive intake of food.

What is Pre-Ramadhan counselling: Many people with diabetes can safely keep fast during Ramadhan after discussion with their doctor. However this decision may vary from person to person based upon his/her physical condition, HbA1c, concurrent complications, age, and type of antidiabetic medications etc. It is always advisable to consult your physician well in advance (at least 2-3 months before Ramadhan) to discuss a plan about lifestyle modification, diet and medication accordingly. This is called Pre-Ramadhan counselling which unfortunately is unheard of in our setting.

Which diabetic patients should avoid fasting: People with type 1 diabetes mellitus (T1DM). There is some evidence to suggest that, as long as they are otherwise stable and healthy, they can do so safely. However, strict medical supervision and focused education is essential. Pregnant women with diabetes (especially those on insulin) are stratified as very high risk and are advised not to fast. Fasting is also not advisable to patients with following issues e.g. Frequent low and high sugars (so called brittle diabetes); hypoglycemia unawareness (patient does not perceive symptoms of low sugars; history of diabetic ketoacidosis or severe hypoglycemic episode during the past three months; Hospital admission for very high blood or low blood glucose during the past three months; Very poor control of diabetes (high HbA1c) or presence of complications of diabetes such as problems with kidneys, heart and eyes; Chronic kidney disease patients especially those on dialysis .Lastly any acute illness during this period prevents a person to fast.

Which diabetic patients can undertake fasting: Well controlled type 2 diabetic patients on diet therapy or on any of these drug classes viz; metformin, second generation sulphonylureas, Incretin mimetics, glitazones, SGLT2 inhibitors and on single dose insulin can undergo fasting safely.

What dietary alterations can I make: Keep sensible portions in mind and follow the same guidelines for healthy eating that you do the rest of the year with an emphasis on whole grains, lean sources of meat, fish and poultry, small amounts of heart healthy fats and limit added sugars. The meals should be varied and should not consist of only dates, sweet drinks and fried rice. Meals should include extra fiber, which is found in whole grains, legumes, vegetables, salads, and fruits. Fiber helps to avoid constipation. There should be low intake of salt especially with pickles and salted sauces. Suhoor meal should contain a balance of whole grains, apple, nuts, legumes (complex carbohydrates) as well as some protein (lean meat) to help slow the digestion and help the feeling of fullness last as long as possible into the day. Try to take Suhoor meal a little late. (of course within stipulated time) to spread out you energy intake more evenly.

Traditionally the fast is ended (Iftaar) with the eating of dates and drinking water. Limit intake of dates to 1-2 each evening. Simple carbohydrates like bread cereals ,rice or pasta can be taken. Chose water as your main drink. and take plenty of water and sugar free beverages throughout the evening, While I agree that the Iftaar meal is a celebration time, but aim is not to overeat.

Avoid caffeine beverages as they can be dehydrating. Limit the amount of ladoos, jalebi and barfi. Avoid energy dense foods like samosas, pakodas, parantas, purees, ghee, margarines and butter. Limit the amount of oil in cooking to 2 tablespoons for a four-person dish. Here is an example of a healthy Ramadhan plate eg 1 cup of vegetables, 2 cups of whole grain rice, a cup of beans/lentils/peas, a small portion (4 oz) of lean protein. Add one small slice of watermelon, 2 dates and one glass of low fat milk.

Can I go for exercise during fasting: Avoid moderate to highly vigorous exercise However, patients can continue with their routine morning walks and time spent during Taraweeh prayers should be counted as part of exercise activity.

What about alterations in anti-diabetic medications: Individualization of anti diabetic treatment options is the proper approach .Consult your doctor for changes in medications schedule and alteration in insulin regimes. In fact your previous year’s successful Ramadhan experience is a useful guide for changes in drug regimens. Oral drugs that are safe include Metformin, Glipizide, Gliclazide, Glitazones, DPP4 inhibitors, Incretin mimetics, SGLT2 inhibitors, Rapid acting insulin analogues are preferred due to less chances of low sugar and minimal post meal sugar spikes. Premixed insulin [50/50} is a good option in patients who are on two doses of insulin.

Can I do fingerprick sugar tests during fasting: Self monitoring of sugars can be done at home. It does not amount to breaking a fast, Ideally it should be done multiple times a day, However you can do it Pre-Suhoor and Pre-Iftaar and whenever symptoms of low sugar are felt.

At what level of sugars I may have to break my fast: A fast will have to be ended if glucose levels fall too low (usually less than70mg/dl ) or if it shoots up to more than 300mg/dl . For low sugars about 15 grams of carbohydrate can be taken to raise glucose levels to normal. Carbohydrates can be taken in the form of 4 glucose tablets, or fruit juice or candy. Wait for 15 minutes and recheck sugar level again and adjust the medications accordingly. For high sugars apart from increasing the doses of medications, a doctor’s consultation is a must before one continues with fasting. Remember high sugars can lead to dehydration and changes in mental status.

Do I need to go for a Post Ramadhan follow up: A follow up meeting with your doctor is advisable to assess how you handled fasting and to discuss medication readjustments. Lastly remember Eid- ul Fitr is not the time of overindulgence. May the blessings of Ramadhan be on all of us and may Allah grant our prayers and fasts, Ramadhan Kareem!

Dr Mohammad Hayat Bhat is Consultant Endocrinologist at Govt Superspeciality Hospital, GMC, Srinagar