A patient suffering from diabetes observed fast on the first day of Ramadhan-the holiest month of the Muslim calendar. At 3 pm, he started feeling shakiness, higher heart rate, vomiting and was sweating profusely. Since his family was aware about his medical condition, they immediately checked his glucose level which was found to be 38 mg/dL – a very low level. So, he was advised to end his fast. The patient had taken his morning dose of medicine at Suhur(compulsory pre-dawn meal for fasting). His medicines included metformin 1-gm, sitagliptin-50 mg and glimepiride-2 mg, each tablet twice a day. So, what was his mistake? Probably he should have discussed his condition with his doctor before the start of Ramadan and got his medicines schedule adjusted. All patients with diabetes should discuss with their doctors before they start fasting. They should be aware of all precautionary measures they need to take in order to make fasting safe experience. This Ramadan, many of the 1.8 billion Muslims around the world observe fasting. Throughout the month, they abstain from eating and drinking during day – for nearly about 15-16 hours, depending upon the geographic location. All of this can be a challenge for individuals with diabetes.
There is no prohibition on fasting for patients with diabetes provided they observe some precautions. There are a few high-risk category patients for whom fasting can be problematic. Firstly there are patients with type-1 diabetes, which usually occur in children and require several doses of insulin daily. For such patients observing fast can prove fatal. They are more likely to develop low or high sugars. Secondly, elderly patients who have longer duration diabetes (>15-20 years), and uses many shots of insulin daily. They may face problems of low sugars or dehydration if they choose to fast. Thirdly, there are diabetic patients who also have kidney, liver or heart diseases and have been put on medication. They too can face complications. Fourthly, those patients who have had experienced very low sugars in the recent past. They should not be fasting. For all other diabetic patients, observing fast during Ramadhan is probably safe. Those patients who take controlled diet and exercise or who take medicines that do not cause low sugar such as metformin or gliptins (sitagliptin, vildagliptin, linagliptin), there should be no problem with fasting. They should continue their medicines in usual doses. Those individuals who use insulin once or twice a day and are on medicines that cause low sugars such as glimepiride, gliclazide or glipizide, they should discuss with their doctors before observing fast. They either need reduction in medicine doses or rescheduling their medicine regimen. For those patients who are on two doses of insulin per day, morning (Suhur) dose should be reduced by half while evening dose should not be changed. It is important to remember that diabetic patients, who observe fast, should be careful and recognize any symptoms of low sugars such as shakiness, sudden onset of profuse sweating, higher heart rate and sensations of vomiting and intense hunger. They should immediately check their glucose level if it can be done without delay, otherwise break their fast straightaway. Patients with diabetes should get up early at Suhur and drink plenty of water. Maintenance of proper hydration is a good habit, especially during Ramadhan. Sugary food items should be avoided. Instead cereal made food items, fruits and fresh salads without oily dressings, lentils and curd, steam-cooked or boiled vegetables, non-vegetarian items grilled or steam cooked, instead of frying, should be made part of the diet. In daytime, you can maintain your usual level of activity but avoid direct sun in late afternoons, as there are increased chances of dehydration. At Iftar (post-sunset meal) and thereafter, the diabetic patients should be encouraged to drink sugar-free drinks, water or milk to quench thirst. Packed fruit juices and sweets should be avoided. These things cause rapid surge of glucose in blood. Instead fresh fruits and vegetable salads should be made compulsory part of the diet. Also, one should limit use of deep fried and oil rich food items such as Puris and Pakodas. Remember, moderation in eating is the key to good health even in the month of fasting.
Dr M Shafi is a consultant endocrinologist in Medanta, the Medicity Hospital, Gurugram