This article looks at management of diabetes during Ramadan when fasting can put patients at an increased risk of hypoglycaemia, hyperglycaemia and dehydration. These risks are also augmented because the month of Ramadan now falls in the summer.
Diabetic patients and fasting
The problem with diabetes and fasting
Fasting effects on the body
Insulin levels during fasting
Pregnancy and fasting during Ramadan
Exemptions from fasting
Recommendations on management of diabetes during Ramadan
Management of patients with type 2 diabetes
Management of patients with type 1 diabetes
Ramadan occurs on the ninth month of the Islamic Calendar. This calendar is based on a lunar calendar. It is because of this that the length and duration of a fast varies. In summer a fast can last up to 19 hours and in the winter up to 10 hours. The month of Ramadan lasts 28–30 days and aims to teach Muslims self-discipline as well as sympathy for the poor. Most Muslims eat two meals: a pre-dawn meal (sehri) and a post-sunset meal (iftari). They are not allowed to eat or drink anything in between.
Diabetes affects 4% of the Caucasian population, however it affects a grossly increased number of Pakistani men and women (22%), as well as Bangladeshi men and women (27%).1 The number of Muslims in the UK living with diabetes is thought to be 325,000.1 This highlights a significant target population, with the need for diabetic education during the month of Ramadan.
Most diabetic patients consider themselves to be healthy, since they are asymptomatic. Thus they fast during Ramadan, and put themselves at an increased risk of hypoglycaemia, hyperglycaemia and dehydration. These risks are also augmented because the month of Ramadan now falls in the summer. The increased temperatures and length of the fast especially increase the risk of dehydration. Another challenge is that diabetic patients are unaware they are exempt from fasting, since they believe it is compulsory for every Muslim.
Ensuring the safety of the diabetic patient during fasting it is also recommended they take regular blood glucose measurements. However, some Muslims believe they break their fast by doing so. This review aims to look at the current evidence for the best advice on managing a diabetic Muslim patient, during the month of Ramadan.
PubMed databases were searched using the key words ‘diabetes’, ‘Ramadan’, ‘fasting’ and ‘guidelines’ between 2009 and 2014. Twelve articles were identified for the purpose of this review. One of the key words (guidelines) was removed to broaden the number of articles identified as it was felt the previous search was too limiting. This time 167 articles were identified and an additional filter was placed searching for only review articles. This ensured the best form of evidence in the hierarchy of evidence. Placing this filter yielded 21 articles. Each article was then systematically analysed for relevance. No articles were discarded.
A significant reduction in body weight and glucose levels was found to occur during Ramadan.2 A study conducted on 137 Jordanian adults demonstrated this; however, no changes were reported on triglyceride and total cholesterol levels.3
Insulin is released from the islet cells of the pancreas when we eat. Insulin stimulates glycogenesis, which is a process where glucose is stored as glycogen in liver and muscle. During fasting, catecholamines and glucagon are increased. These are counterregulatory hormones that stimulate gluconeogenesis and glycogenolysis. Fatty acids are also released and are then oxidised to produce ketone bodies as an alternative source of energy for the body.
Although pregnant women are exempt from fasting, some still insist on doing so. Studies conducted in Turkey3 and Tunisia4 showed an increase in plasma HDL-cholesterol levels of 20%. No negative effects on fetal development were noted. However, it is imperative to keep in mind that these studies were done on healthy women with no history of hyperglycaemia and ketoacidosis.
Complications are also compounded in type 2 diabetic patients who, as a result of the side effects of their medication, are at an increased risk of developing hypoglycaemia.5 If these patients present with autonomic neuropathy, they may also have an inadequate response to hypoglycaemia.
The EPIDAR study was the largest of its kind. It consisted of 12,243 diabetic patients in 13 countries. The retrospective population study showed no significant change in glucose concentration or weight in patients with diabetes.6 However, the study demonstrated an increased risk of severe hypoglycaemia leading to hospitalisation. This risk was greater for type 2 diabetics (7.5:1) compared to type 1 diabetics (4.7:1).6 The risk of hyperglycaemia was also increased in type 2 diabetics (5:1) compared to type 1 diabetics (3:1).6
Is there a reduced cardiovascular risk in diabetic patients when fasting?
Several studies have reported an increase in HDL cholesterol levels during fasting. However this effect does not last once the patient commences their normal eating habits. An increase in HDL suggests there may be an equal decrease in cardiovascular risk. Despite this, a survey reported an increased risk of retinal vein occlusion during Ramadan.7 It is thought cholesterol levels are not responsible for this and it may be a result of dehydration.7
An international meeting of healthcare professionals with a specific interest in Ramadan and diabetes was held in 1995. Based on religious rulings and scientific reasoning they concluded the following certain groups should be exempt from fasting (Table 1). In addition to this, they also permitted fasting in diabetics with stable disease.8
|TABLE 1: GROUPS WHO SHOULD BE EXEMPT FROM FASTING ACCORDING TO THE DIABETIC MEETING IN MOROCCO 19958|
|Type 1 diabetics|
|Type 2 diabetics|
|Diabetes with complications|
|Pregnant women with diabetes|
Working with the patient
Patients with diabetes who wish to fast during Ramadan should book an appointment with their GP at least two months before it begins. During the appointment, the doctor should carefully phrase the risks of fasting and explain the religious exemptions. This would ensure the patient adheres to this advice and that their cultural or religious values are not offended. An appropriate lifestyle, drug and diet plan should be drawn up tailored to patients individualised needs.9
The appointment should include a full annual review, measurements of HBA1c, blood pressure and lipids.10 It should also highlight the complications of fasting with family members including educating them on the symptoms of hypoglycemia and hyperglycemia. Most importantly, the GP needs to explain when to break the fast.2,9
Patients should also be given a blood glucose monitoring device to help monitor their blood glucose levels during fasting. This is particularly important in patients with type 1 diabetes and in patients with type 2 diabetes that require insulin. Figure 1 shows the basic outline of the consultation that should take place.
The need for patient education
A large observational study9 highlighted such a need. In the study, patients were divided into two groups: those that would be given patient education on fasting and those who would not. Those who were given patient education had a significant reduction in hypoglycaemic events (400%), compared to those patients who were not given such an education session.
It is common practice to ingest a large amount of foods, rich in carbohydrates and fats, during the sunset meal. This practice has been advised against. Instead foods rich in complex carbohydrates are encouraged as this will delay the digestion and hence absorption of the food.
This will hence prevent any abrupt changes in blood glucose levels and minimise complications of hyperglycaemia.9 As much fluid as possible is also encouraged during fasting hours to minimise the complication of dehydration.
When to end fasting?
Patients need to understand that they must immediately end their fasting if blood glucose levels fall below 3.3mmol/l at any time. If blood glucose levels fall below 3.9mmol/l in the first few hours into fasting, the fast should also be ended. To minimise the risk of hypoglycaemia excessive exercise is discouraged. On the other hand, if the blood glucose levels are more than 16.7mmol/l the fast should also be broken. Many patients with diabetes who fast during Ramadan are heavily dependent on religious leaders for advice. Hence it is important to involve them in patient care and to offer any advice with the support of religious text.6,10
The management of these patients who are normally low risk compared to type 1 diabetic patients is summarised in table 2.
|TABLE 2: MANAGEMENT OF PATIENTS WITH TYPE 2 DIABETES10,14|
|Patient treated with:||Can they fast safely or not?||Change in medications or advice|
|Diet||Yes||Eat smaller meals with a high glycaemic index
Adequate fluid intake to minimise thrombosis5
|Metformin||Yes||Take one-third at dawn and two-thirds at dusk5,8|
|Thiozolidinediones||Yes||Take medication as normal
If combination treatment 0.5 taken at dawn and 1.5 taken at dusk
|Sulfonylurea||Yes but with caution||Prandial regulators and short acting agents should be used to manage diabetes during Ramadan|
|Incretin-based therapies||Yes||No adjustment if used alone|
|Insulin||Yes but with caution||Reduce dose of long-acting insulin by 20%
Pre-mix insulin: morning dose should be taken at dusk and half of evening dose
Type 1 diabetics, with poorly controlled diabetes, should not fast.5 Despite this, significant amounts of patients (43%) do fast according to the EPIDIAR study.6 Two small studies have suggested the use of glargine for diabetic fasting patients. It has been shown to cause less hypoglycaemia.11,12 Another study has suggested insulin lispro as an alternative. Patients given this regimen had reduced hypoglycaemia events.13
Fasting is a central pillar of faith for many Muslims, hence many engage in fasting despite the health risks. The EPIDIAR study showed a significant proportion of diabetic patients continued to fast knowing the risks. Healthcare professionals may need to come to terms with this notion. However, a systematic pre-Ramadan assessment, which educates the patient on identifying symptoms of hypoglycaemia or hyperglycaemia would enable them to fast in safety. Although many reviews have offered guidelines for managing diabetic patients there are still no solid national guidelines.
The studies that do offer advice on managing type 2 diabetic patients have been conducted in the Middle East or in regions where there is little time zone changes between summer and winter. The guidelines and advice may need to be reviewed in relation to European countries where fasts are much longer (19 hours during summer). Randomised control studies are needed on the effects of medication changes during Ramadan and their success in reducing complications. Studies are also needed to examine the effect of patient education on the incidence of hyperglycaemia or hypoglycaemia. Ramadan is also the best time to encourage patients to give up smoking since the theme of the month is self-control. Many patients have reported they found it easier to quit during the Ramadan period.
Affaq Razaq, 4th year medical student, Manchester Medical School, University of Manchester
Conflict of interest: none declared
6. Salti I, Bénard E, Detournay B, et al. EPIDIAR Study Group A population-based study of diabetes and its characteristics during the fasting month of Ramadan in 13 countries: results of the epidemiology of diabetes and Ramadan 1422/2001 (EPIDIAR) Study. Diabetes Care 2004; 27: 2306–11