amadan is one of the 5 pillars of Islam. Fasting during Ramadan has been an age old tradition observed by millions of Muslims across the globe, lasting between 29 to 30 days.
Diabetes affects many Muslims, and a common question asked by patients is whether fasting during Ramadan would be a problem, and whether medications need to be changed.
The Qur’an, the sacred text of Islam, clearly states that people who suffer from a medical condition may be exempt from fasting, especially if fasting is potentially harmful. However, many people insist on observing the fast during Ramadan, bearing in mind the potential risks.
What Are The Potential Problems Of Fasting During Ramadan?
Before we look at how diabetes can be managed during Ramadan, it is important to understand what effects fasting can have on diabetes.
It must be stressed that observing fast during Ramadan can have multiple complications on the health of individuals with diabetes. While most medical professionals will respect the tradition, the advice is very likely going to be the same – if possible and permissible avoid fasting during Ramadan.
Reduced food intake during Ramadan increases the risk of development of hypoglycemia.
In individuals with type 1 diabetes observing the fast, clinical studies have shown that 4 out of 100 people may die from hypoglycemia.
There are no clear statistics in individuals with type 2 diabetes, though the available clinical evidence suggests that fatality is rare.
Contrary to expectation, some individuals with type 2 diabetes may notice a marked increase in their blood sugar.
In a clinical study, it is found that individuals had Type 2 diabetes had a five-fold increase in the development of excessively high blood sugars (hyperglycemia).
While the explanations are many, this increase in blood sugars is likely due to a reduction in the medication taken against medical advice.
The hyperglycemia that may occur during Ramadan can predispose people to diabetic ketoacidosis. A likely explanation for this is the reduced insulin dose taken during this period.
As fasting requires no intake of food or water, dehydration may occur especially if the surrounding climate is hot and humid.
Dehydration is often accompanied by hyperglycemia. The high blood sugar will lead to an increase in urination which in turn leads to loss of important salts and electrolytes from the blood.
Dehydration can lead to dizziness and low blood pressure. This can predispose individuals to falls and injuries.
Dehydration can also make the blood thicker. This increases the chances of developments of blood clots i.e. thrombosis. Thrombosis can lead to a heart attack or a stroke.
Hydration is key to managing diabetes during Ramadan.
If you are about to begin your Ramadan fast, it is important that you pay attention to the following important issues.
Monitor your blood sugars frequently
If your diabetes has not been well controlled or you have been taking insulin to manage your blood sugars, it is important that you watch your blood glucose levels at home several times a day.
Eat a healthy balanced diet
Dietary advice during Ramadan does not change. Do not indulge in high carbohydrate high-fat diets just because you are about to begin your fast. Instead, continue to observe a healthy balanced diet and consume plenty of liquids
If possible, make sure your early morning meal is as close to sunrise as possible. Keeping it simple and well balanced is a good way of managing diabetes during Ramadan.
Limit your physical activity
You are welcome to continue your household activities and daily activities during Ramadan. However, excessive physical activity such as running or cycling is not recommended.
The Taraweeh prayers
These are night long prayers performed after the sunset meal. They are to be considered a part of the day-to-day physical activity. These prayers can last up to 2 hours and the exertion required can lead to hypoglycemia and dehydration.
It is therefore advised that patients performing these prayers eat starchy foods with Iftar (the evening meal) and increase their overall fluid intake.
Know when to break the fast
If you are monitoring your blood sugar levels during your fasting period, it is important that you recognise when to break your fast in the interest of maintaining your health.
If your blood sugar level is below 60 mg/dL (3.3 mmol/l), then end your fast.
If your blood glucose levels drop down to 70 mg/dL (3.9 mmol/l) within the first few hours of starting your fast (following your medication), then end your fast.
If your blood glucose levels rise above 300 mg/dL (>16.6 mmol/l), then end your fast.
The choice of course is entirely up to you. Discuss the pros and cons of fasting with your doctor well before you start Ramadan, ideally 1 – 2 months before the festivities begin.
Managing Diabetes During Ramadan
If you are someone who manages their Type 2 diabetes with diet and exercise alone, then the risk of your blood sugar dropping down too much is very low. However, make sure you watch how much food you eat as excessive food intake can drastically increase the blood sugar levels leading to hyperglycemia.
A simple solution is to break your food intake during the non-fasting period into 2 to 3 small meal portions.
If you are taking metformin alone, it is very unlikely that you will suffer from hypoglycemia i.e. low blood sugars. Metformin can reduce HbA1c levels by 1 to 2% as well. However, there are no clinical trials that have specifically studied the effect of metformin on blood sugar levels during Ramadan.
The dose of medication may be changed a little. You may be asked to take about two thirds of the total dose before your sunset meal and one third of the dose before the early morning meal. Ask your doctor for more advice.
Sulphonylurea drugs (glimipride, gliclazide, glibenclamide) have a risk of hypoglycaemia and may be stopped by your doctor.
DPP-4 inhibitors (Vildagliptin, Sitagliptin and other ‘gliptins’)
When used alone, these drugs do not necessarily reduce blood sugar values to dangerous levels. Comparing sulphonylureas to DDP 4 inhibitors, the chances of blood sugar levels dropping are less. This makes using gliptins as single therapy safe during Ramadan. Combining them with sulphonylureas increases the risk of hypoglycaemia however.
If you are taking insulin, then the dose may be reduced according to your food intake. Longer acting insulins that are combined with short acting insulin may be administered just before meals.
Fasting and Pregnancy
Fasting during pregnancy places the growing fetus at a great deal of risk. Tradition recommends that pregnant Muslim woman refrain from fasting during Ramadan. Women who suffer from diabetes before or during pregnancy are at a very high risk and are advised to avoid fasting.
In those who insist on fasting, it is essential that the right advice be sought regarding managing your blood sugars when you are pregnant. A number of different medical teams may need to work in close association with each other to help control diabetes and to allow for a safe pregnancy and delivery.
Knowledge is Power
Clinical studies have shown that understanding the management of diabetes during Ramadan can help prevent episodes of hypoglycemia and weight gain.
So if you wish to observe the fast, make sure you read this article again to understand what’s important when it comes to managing your blood sugar.
In a Nutshell….
Recommendations To Control Blood Glucose During Ramadan
1. Monitor your blood glucose regularly. Do it several times a day if possible.
2. If you are taking insulin, check your blood sugars before, during and after fasting
3. See your doctor at least 1 – 2 months before Ramadan begins. That way your doctor has enough time to adjust your medication and control your blood sugars.
4. Avoid skipping meals.
5. Avoid excessive or strenuous activity during the fasting period.
6. Adjust your medication and follow the advice of your doctor.
7. If your sugar levels are dangerously low, consider breaking your fast as it could save your life.
8. Record your blood glucose pattern by monitoring your sugar at home. This will help guide you on how your blood sugars are responding during Ramadan.
If hypoglycemia does occur, make sure you know how to correct it.
Ramadan is a widely observed festival in the Muslim community. Concerns about blood sugar levels and diabetes control are not unfounded. However, simple measures and following the advice of your doctor can help you have a safe Ramadan.
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