Diabetes and Ramadan
Ramadan is the 9th month of the Islamic calendar, during which Muslims observe a period of fasting. This observance is incumbent upon all believers and is considered one of the Five Pillars of Islam. The date of Ramadan varies from year to year, since the Islamic calendar is based upon the cycles of the moon. During this 29-30 day period, Muslims take meals before sunrise and after sunset, but refrain from food, liquids, and smoking in the interval between. Exceptions to this rule are permitted in situations which might cause increased health risk. Many people with diabetes do choose to observe the fast, and they can do so safely with the help of an experienced health professional who understands the religious rules and constraints, and appreciates the situations in which the fast should not be undertaken. This article explains the management of diabetes during Ramadan.
A. Case Scenario
A 43 years construction engineer, who works in a new busy project was diagnosed with T2D five years ago. He is currently treated with Metformin 850mg bd, Gliclazide 80mg bd. His HbA1c is 8.1%. During his review he asks your advice as he’s a Muslim and he always fasted during the month of Ramadan. He’s not sure how can he improve his glycaemic control and at the same time fulfill his passion to fast the month of Ramadan. What is your advice?
This is a common case scenario for many doctors, as Muslims constitute 23% of the world population and 20% of them live in countries where Islam is not the main religion of the country. The case scenario here could easily be a young adult with type 1 diabetes, a pregnant woman with diabetes or indeed an older person who also have other co-morbidities. So surely there are several challenges here. To try to address these challenge we need to look into the following points:
- What is Ramadan? Is fasting Ramadan a common practice by many Muslims with diabetes?
- Are there risks associated with fasting Ramadan for people with DM?
- Who should not fast? Will they accept my advice?
- What can I do to minimize the risks of fasting Ramadan for people with DM?
- Are there any necessary changes for diabetes medications?
What is Ramadan? Is fasting Ramadan a common practice for Muslims with diabetes?
Ramadan is the ninth month of Muslim calendar, and as it is a lunar calendar, it is about 11 days shorter than the Christian calendar. Consequently, Ramadan is usually about 11 days earlier every year. Ramadan is a holy month for Muslims. Fasting Ramadan as this is one of the five main pillars of the Muslim faith. This is a must for every healthy adult Muslim. More than 75% of people with type 2 diabetes and over 40% of people with type 1 diabetes fast during Ramadan. Fasting starts from dawn to sunset, which in the northern hemisphere could range from 15-18 hours is summer months. During these hours any fasting Muslim should not eat, drink or smoke. However, the Koran clearly exempts the following people from fasting:
- Any sick person
- Women who are pregnant, breast-feeding or during their menses
- During traveling
- Those who have reduced mental capacity for whatever reason
Are there risks associated with fasting Ramadan for people with DM?
While most Muslims with diabetes fast without reported risks to their health, healthcare professionals should familiarize themselves with the various possible risks that some people with diabetes may develop during fasting Ramadan. The main risks reported in the literature are:
- Hyperglycemia with or without Diabetic ketoacidosis
- Dehydration and thrombosis
It is important to be aware that if the reason for not fasting is temporary, the person can compensate for the non-fasted days later in the year> If however the reason is permanent, the person affected will instead give money to the equivalent of the cost of his daily food to a poor person if he’s financially able to do so.
Who should not fast? Will they accept my advice?
As mentioned previously the Quran exempts the ill person from fasting, however, the severity of diabetes varies vastly among different people. Hence, it is crucial that health care professionals assess the risks to the individual and discuss these with the person with diabetes. This will empower the person to taken their own decision after advice from an experienced professional.
The ADA consensus document published in 2005 and updated in 2010, categorises the risks of fasting during Ramadan in people with diabetes into four levels. Furthermore, the Organization of the Islamic Conference at its 19th session held in the UAE in April 2009 produced a decree following meeting with some diabetes experts who reviewed the medical evidence and the risk categories stated in the ADA 2005 consensus document. The possible risks and the religious decision regarding fasting or not is summarized in the tables below.
These documents encourage a dialogue between health professionals and religious authorities to make people with diabetes aware of these issues, and to increase their acceptance of the advice they are given. This can also help to make religious authorities aware about the importance of good diabetes management to prevent long-term complications.
Categories of Risks in Patients with Type 1 or Type 2 Diabetes Who Fast During Ramadan and the Religious ruling for fasting
|Group 1: Very high risk||Group 2: High risk|
|Severe hypoglycemia within the last 3 months prior to Ramadan||Patients with moderate hyperglycemia (HbA1c >10%)|
|Patient with a history of recurrent hypoglycemia||Patients with renal insufficiency|
|Patients with hypoglycemia unawareness||Patients with advanced macrovascular complications|
|Patients with sustained poor glycemic control||People living alone that are treated with insulin or sulfonylureas|
|Ketoacidosis within the last 3 months prior to Ramadan||Patients living alone patients with comorbid conditions that present additional risk factors|
|Type 1 diabetes||Old age with ill health|
|Acute illness||Drugs that may affect mentation|
|Hyperosmolar hyperglycemic coma within the previous 3 months|
|Patients who perform intense physical labor|
|Patients on chronic dialysis|
Religious Ruling for Group 1+2: Based on the high probability of harm if they fast, hence, they are prohibited from fasting.
|Group 3: Moderate risk||Group 4: Low risk|
|Well-controlled patients treated with short-acting insulin secretagogues such as repaglinide or nateglinide||Well controlled patients treated with diet alone, metformin, or a thiazolidinedione, who are otherwise healthy. (This should also apply to the incretins group of medication although the class of drugs was not available at the time of the religious document)|
Religious Ruling for Group 3+4: Based on low probability of harm, hence they should fast
What can I do to minimize the risks of fasting Ramadan for people with DM?
It is advisable to utilize the passion of the Muslim patient for fasting during Ramadan to motivate them to improve not only glycaemic control, but also all diabetes related problems. Hence, a pre-Ramadan assessment is essential. This ideally should take place 2 months before Ramadan to allow enough time for any necessary changes in medication to be fully effective before Ramadan. It is advisable where possible to offer a structured diabetes education program designed to address diabetes and Ramadan-related issues. Such educational programs should ideally consist of the following three components:
A. General awareness campaign that ideally should include local religious personnel as well as local media people to harmonize the information and increase the general awareness about diabetes and Ramadan management.
B. An advanced training session for health professionals to increase their knowledge and skills about diabetes and Ramadan. This should increase their ability to advise on risk assessment utilizing the local/international management recommendations, and management of diabetes and Ramadan in different types of diabetes with various co-morbidities. The session should ideally include clinical scenarios designed to test knowledge about the various treatment options and modifications required during Ramadan.
C. A patient educational program designed to address diabetes and Ramadan. This ideally should be in the patient's own language and reflect their cultural lifestyle. This will help the person with diabetes to make the appropriate decision as to fast, and will provide the necessary information and skills to allow them to have a safer Ramadan regardless of their fasting decision. This programme should ideally address the following points:
- A discussion on diabetes and possible risks during Ramadan, and the religious rules for the fast.
- Capillary blood glucose monitoring not only for preventing and detecting hypoglycaemia but also to detect hyperglycaemia which is not unusual during eating hours. Self-monitoring of blood glucose will also aid clinical decision-making, and can also help in behaviour change.
- Stressing the importance of stopping the fast immediately if the person has symptoms and/or signs of hypoglycaemia or become ill for other reasons.
- Dietary changes required to avoid hypo and hyperglycaemia as well as the importance of appropriate fluid intake to avoid dehydration.
- The appropriate timing and intensity of physical activity during fasting hours which should also include advise regarding Taraweeh prayers (multiple prayers after the sunset meal) which are offered by many Muslims during Ramadan and should be considered a part of the daily exercise program. These educational methods have been previously shown to be of good value to reduce hypoglycaemia and to stabilize glycaemic control when previously tested in UK for people with type 2 diabetes wishing to fast Ramadan.
Are there any necessary changes for diabetes medications?
Any change in medication during the month of Ramadan should ideally help the patient to fulfill this desire to fast Ramadan safely while maintaining good glycaemic control.
The changes of oral glycaemic agents, GLP-1 analogues and insulins during Ramadan falls under the following categories:
- Changes in type of medication: In general terms due to the potential risk of hypoglycaemia during fasting, it would be advisable to opt for drugs that have a lower risk of hypoglycaemia. This should be applied at any stage of the year when a Muslim person with diabetes requires a drug to improve glycaemic control rather than waiting until few days or weeks before Ramadan.
- Changes in dose of medication: the common practice of excessive reduction of medication to avoid hypoglycaemia should only be implemented in people whom fasting can significantly increase their risk of hypoglycaemia such as those with tight glycaemic control or those who have physically demanding jobs during fasting hours. In these circumstances it’s advisable to reduce the morning dose of hypoglycaemic medications such as sulphonylurea and/or insulin. It is important to understand the eating habits of some people during Ramadan as postprandial hyperglycaemia is a risk for many and an increase in medication before the evening meal may be advisable.
- Changes in timing of medications: Drugs that are administered once daily could be given at evening meal time, while drugs that are required twice daily could be give at the time of the evening meals as well as the early morning meal. Those on medications that are administered three times daily will need to omit one dose. Indeed, this requires careful assessment by their diabetes team members to assess the safety of this and the possibility of a change in dose or type of treatment to avoid any drawback to such decision.
In applying all the above aspects, hopefully the challenge of fasting for most of the day could be an opportunity for the person with diabetes to understand their diabetes better and achieve better diabetes care throughout the year and not only during the month of Ramadan.
Useful Reading material for diabetes and Ramadan:
- The EPIDIAR Study: A population-based study of diabetes and its characteristics during the fasting month of Ramadan in 13 countries. Salti I, et al., Diabetes Care, 2004; 27: 2306-2311.
- Recommendations for management of diabetes during Ramadan, Al Arouj M, et al, Diabetes Care. 2010; 33(8):1895-1902.
- Diabetes and Ramadan: how to achieve a safer fast for Muslims with diabetes. Mohamed M Hassanein.The British Journal of Diabetes and Vascular Disease. 2010; 10(5): 246-250.