The International Diabetes Federation (IDF) and Diabetes and Ramadan (DAR) Alliance have released new guidelines for managing diabetes during the Muslim holy month of Ramadan, when Muslims fast from sunup until sundown, not even drinking water. What should Muslims with diabetes do to stay healthy during Ramadan?
Ramadan this year starts on June 6 and runs through July 5 in most locations. Each year’s dates are different because the holiday is based on a lunar calendar. When it comes in June, the fasting daytimes are longer in the Northern Hemisphere, as long as 18–20 hours in high northern latitudes. Muslims will normally eat a large communal meal (iftar) after sundown and a smaller meal (suhoor) before sunrise, some snacks and fluids if awake at night, and that’s it for the day.
Twelve to 20 hours is a long time to go without water, and dehydration is common, especially in hot weather or while doing physical work. Sugars can go low from not eating. A study of people with diabetes who fasted during Ramadan found that the risk of being hospitalized for hypoglycemia increased by 4.7-fold in people with Type 1 diabetes and by 7.5-fold in those with Type 2.
Fasting can also increase risk of dangerously high blood sugar. “With no food,” wrote Erika Gebel Berg, PhD, “the liver releases stored glucose for energy.” Because people may stop their medicines to avoid lows, blood sugar levels can soar. “In one study, researchers found a fivefold increase in severe hyperglycemia in people with Type 2 who fasted during Ramadan and a threefold increase in people with Type 1.”
Muslim religious leaders stress that no one should endanger their health for religious reasons. People with medical conditions such as diabetes are not required to fast, but many, like former Diabetes Self-Management blogger Maryam Elarbi, want to observe the fast for spiritual reasons.
Elarbi told our readers why Ramadan is important to her. “It’s about much more than simply abstaining from food and water. The month focuses heavily on gaining a stronger sense of spirituality, as well as working to improve yourself in general.”
The new IDF-DAR guidelines, co-written by doctors, researchers, and religious leaders say, “The decision about whether to fast is made on an individual basis in consultation with the patient’s treating physician, taking into account the severity of illness and the level of risk involved.”
One section of the guidelines on religious concerns highlights: “It is essential to insure that those who do not fast due to medical conditions understand that they are indeed rewarded like those who do fast and should not feel guilty.”
Muslims with diabetes should meet with their doctors several months before Ramadan to adjust medications and make a Ramadan nutrition plan and a plan for management during the holy month.
Guidelines originally developed by the American Diabetes Association (ADA) and endorsed by Muslim religious leaders divide people into four categories, based on severity of their diabetes. The new guidelines outline three risk categories — green, yellow, and red. The red, or highest-risk, category includes people with recent history of severe hypoglycemia or hyperglycemia in the three months prior to Ramadan, poorly controlled Type 1, hypoglycemia unawareness, advanced complications, and those who are old and sick. They are advised not to fast.
The yellow, or higher-risk, category includes people with poorly controlled Type 2, well controlled Type 1, pregnant women with Type 2 or gestational diabetes, and those with advanced chronic kidney disease. Doctors should advise people in this category not to fast, according to the IDF guidelines, but exceptions can be made.
The green, or low-risk, category, includes people with well controlled Type 2 diabetes who take no medicines or only those that aren’t associated with low blood sugar (sulfonylureas and insulin are among those associated with the risk of lows).
People in any category who fast should:
• Meet with their doctor a month or more in advance. Receive structured education.
• Be followed by a diabetes team.
• Check their blood sugars regularly (which some Muslims wrongly believe breaks their fast).
• Modify medications as recommended by their doctors. Health-care providers may discontinue use of older sulfonlyureas, but will likely continue metformin, acarbose, thiazolidinediones, glinides, newer sulfonylureas, SGLT-2 inhibitors, DPP-4 inhibitors, GLP-1 receptor agonists, and short-acting and basal insulins, perhaps at modified times or doses.
• If your doctor is not familiar with Ramadan, give him the link to the IDF guidelines and ask him to read them. There are about 35 pages of advice about all different types of diabetes meds.
• Be prepared to break the fast in case of low or high sugars and stop the fast if the problems keep happening.
• At the iftar meal after sundown, eat low-glycemic-index carbohydrates, such as fruits, vegetables and salads; protein; and some fat. Don’t eat a lot of sweetened desserts. You can find Ramadan nutrition plans in the IDF guidelines or with a Google search for those terms.
• Stay well hydrated between sunset and dawn, avoiding sweetened drinks and caffeine.
• Vigorous exercise is discouraged, but light to moderate exercise is recommended. Remember that the physical exertion during prayer should be counted as exercise.
Some sites for Muslim athletes give ways to maintain a workout schedule during Ramadan. Don’t exercise while fasting, but instead at night after eating and drinking.
• Eat the morning meal (suhoor) as late as possible to reduce hypoglycemia during the day.
• Break the fast if your sugar goes below 70 mg/dl or over 300 mg/dl, or if you get symptoms of hypoglycemia or hyperglycemia.
Although not mentioned in the guidelines, it seems highly advisable to stay out of the heat and avoid physical labor as much as possible. If this is not possible, monitor more strictly.
Have a blessed and rewarding Ramadan!