GK: Is fasting possible for a diabetic?
Prof Laway: Fasting during the holy month of Ramadan forms one of the five pillars of the Muslim faith. Within the Muslim community, there is an intense desire to participate in fasting, even among those who are eligible for exemption.
The duration of fasting is over 14 hours during the month of April and May and days would be ranging from warm to hot. Approximately 50 million Muslim adults with diabetes go without food or drink from sunrise to sunset during the month of Ramadan, despite having a religious exemption.For many Muslim people with diabetes, Ramadan is a religious conviction and the intermittent fasting is a key component of its observance. In patients with diabetes, fasting can sometimes be detrimental.
GK: What are the risks associated with fasting?
Prof Laway: Risks associated with fasting stem both from daytimerestriction on eating and nighttime indulgent eating and feasting, these together with hot and humid conditions make many complications more likely. The risks of fasting to patients with diabetes include: low blood glucose, high blood glucose and dehydration.There also is an increased risk of clotting of blood in the vessels(because of dehydration and high blood glucose).Keeping these complications and balance of religious sentiments in mind, experts have recommended some guidelines for the physicians, patients and their caregivers.
GK: Among diabetics, who can fast safely?
Prof Laway: According to these guidelines, following group of patients can safely fast during Ramadan:
Those with well-controlled diabetes treated with one or more of the following: lifestyle therapy, metformin, acarbose, thiazolidinediones, second-generation sulfonylureas (like glipizide, glimpiride and gliclazide), incretin-based therapy (DPP-4 inhibitors or GLP-1 RAs), SGLT2 inhibitors, and basal insulin. To carry on fasting safely, this group of patients also should take advice from the physician and monitor blood glucose frequently.
GK: Who should not fast then?
Prof Laway: Because of high risk of fatal complications during fasting, a patient with diabetes with one or more of the following should not fast:
- Type 1 diabetes
- Poor blood sugar control (HbA1c of > 8.5%)
- History of ketoacidosis during 3 months before Ramadan
- Very high blood glucose during 3 months before Ramadan
- Advanced heart, liver and kidney disease
- Cognitive dysfunction, epilepsy
- Recurrent hypoglycemias (episodes of low blood glucose)
- Severe hypoglycemia(low blood glucose needing assistance of another person to treat) in last 3 months before Ramadan
- Patient getting low blood glucose without symptoms
- Pregnant women
- Acute illness including diabetic foot or foot ulcer
- People taking intense physical labor
GK: What is your diet advice for patients during Ramadan?
Prof Laway: People generally tend to overeat during Ramadan and diet is typically rich in carbohydrate and fat resulting in uncontrolled diabetes. Because of fear of hypoglycemia, people tend to overeat during suhur also. Blood glucose control may also be disturbed because of iftar parties.
A healthy balanced diet and distribution of calories into 2-3 servings during non fasting hours helps in control of diabetes. Pre dawn meal (suhur) should mainly comprise foods rich in complex carbohydrates like whole grain cereals, vegetables such as beans and lentils and fruits. Eating dates traditionally marks the end of a fast but are very rich in sugars; a portion of 1-2 dates may however raise blood glucose.
Dinner should be taken as early as possible after iftar and should mainly consist of a combination of whole wheat flour chapattis, vegetables and small amount of meat, salads should be taken to increase the fibre content. A late night snack with a glass of milkor a portion of fruit will maintain a normal blood glucose till suhur time. Non caloric fluid intake should beincreased during non fasting hours.Avoid caffeine- based drinks such as tea, coffee and cola. Caffeine results in excessive urination and hence results in water loss from the body.
GK: What about exercise and Taraweeh prayers during Fasting?
Prof Laway: Light and moderate exercise is safe. Rigorous exercise is not recommended as this increases the risk of hypoglycemia (falling glucose level) especially if on insulin or oral drugs. Taraweeh prayers and walking to the mosque should be accounted for in the exercise regimen. Individuals should carry water and rapid acting carbohydrate drink (for correction of hypoglycemia in case such a thing happens). It is better to go for an exercise like daily walk after suhar or iftar. A person going for Taraweeh prayers does not need to go for a regular walk
GK: How does one monitor blood glucose during fasting?
Prof Laway: First, blood glucose monitoring during fasting does not break the fast. Therefore, monitor blood glucose levels at the beginning of the fast at mid day and before iftar. Blood glucose levels should be checked if any symptoms of hypoglycemia (low blood glucose) such as increased appetite, sweating, nervousness or any unpleasant feeling or if the patient becomes unwell.
GK: When does a patient need to end fasting?
Prof Laway: At any point the patient feels unwell, fasting should be terminated. The following indicators should be kept as guidelines:
- Blood glucose levels are 75mgs/dl at any time during the fast
- Blood glucose levels > 300mgs/dl any time during the fast
- Symptoms of hypoglycemia(like increased appetite, sweating, nervousness or any unpleasant feeling) even if blood glucose level is normal
- Patient feels unwell
GK: Are any changes in medications recommended during Ramadan?
Prof Laway: Best, discuss with your doctor. The general rules:
- For patients taking Metformin, Pioglitazone, Gliptins, Acarbose, Voglibose, SGLT2 inhibitors and GLP1 receptor agonists, no change in medication required
- Once a day sulfonylureas dose is to be taken after iftar
- Twice a day sulfonylureas: Morning dose to be halved and taken with Suhur, evening dose remains same
- Basal insulins like NPH, glargine(lantus,baselog,basugine, glaritus), degludec (tresiba) : reduce daily dose by 20% and give at bed time
- Insulin 30/70, twice daily or Humalog mix/Novomix twice daily: Morning dose to be taken after iftar, evening dose to be reduced by half and taken before Suhur
GK: Your summarized advice?
Prof Laway: Despite intense desire to fast, a pre Ramadan advice should be taken from a physician regarding its associated risks. Experience from the previous Ramadan can act as a guide in the current month; particular attention should be paid at diet, exercise, glucose monitoring and avoidance of hypoglycemia.
Prof Bashir Ahmad Laway is head Department of Endocrinology at SKIMS Soura. He can be mailed at drlaway@gmail.com