During the Ramadan period it is crucial that people living with diabetes are offered support with ensuring the optimal management of the diabetes as they fast.
There are guidelines that have been developed by the International Diabetes Federation (IDF) and the Diabetes and Ramadan (DAR) International Alliance. The guidance available represents expert opinion rather than medical evidence.
In this article we aim to provide some practical guidance on optimizing the management of diabetes for people who are fasting during this Ramadan period.
Fasting during Ramadan has been shown to result in a number of physiological effects. Particularly in diabetic patients, these changes and the type of antidiabetic medication being taken can lead to complications such as hypoglycaemia (low blood glucose levels) and hyperglycaemia (high blood glucose levels). Why do these changes happen?
- Fasting alters the timings of meals
- Disturbs sleep patterns and the circadian rhythm
- Ensure that meals are well balanced i.e. 45-50% carbohydrate, 20-30% protein and <35% fat (preferably mono- and polyunsaturated)
- Divide daily calories between suhoor and iftar, plus 1-2 snacks if necessary
- Include high fibre foods that release energy slowly before and after fasting e.g. granary bread, beans, rice
- Include plenty of fruit, vegetables and salads
- Minimise foods that are high in saturated fats e.g. ghee, samosas, pakoras
- Avoid sugary desserts
- Use small amounts of oil when cooking e.g. olive, rapeseed
- Keep well hydrated between sunset and sunrise by drinking water or other non-sweetened beverages
- Avoid caffeinated and sweetened drinks
- Engage in light-to-moderate exercise
- Physical exertions involved in Tarawih prayers, such as bowing, kneeling and raising, should be considered part of their daily exercise activity
- Avoid rigorous exercise during fasting because of the increased risk of hypoglycaemia and/or dehydration
- It is important to have an assessment done for any patient with diabetes who intends to fast in order to evaluate the risks, get educated in self-management of the condition during Ramadan and to produce a patient-specific treatment plan
- Patients taking metformin, short-acting insulin secretagogues (nateglinide or repaglinige), sulphonylureas (e.g. gliclazide, glimepiride etc.) or insulin will need to make adjustments to dose and/or timings to reduce the risk of hypoglycaemia while maintain good glycaemic control. For example, with Metformin the most commonly used first-line oral anti-diabetic drug, severe hypoglycaemia in non-fasting patients is rare, and although no trials have been conducted with patients with Type 2 Diabetes (T2DM) during Ramadan, it is considered safe to continue while fasting because the likelihood of hypoglycaemia is low. However, some dose timings adjustments may need to be made e.g. moving a three times daily dosing regimen to twice daily; with the midday dose moved to iftar.
- Newer oral anti-diabetic drugs such as incretin-based therapies (e.g. Sitagliptin, Saxagliptin, Exenatide, Liraglutide) are associated with lower risk of hypoglycaemia and may be preferable for use during Ramadan, for some patients following an assessment.
- SGLT2 inhibitors or gliflozins (e.g. canagliflozin, dapagliflozin, empagliflozin) are probably safe but should be used with caution in some patients. There is need for more data regarding their use during Ramadan.
- Patients classified as very high/high risk including Type 1 diabetics and pregnant women with diabetes need close medical supervision and focused Ramadan-specific education if they choose to fast
- A post-Ramadan follow-up consultation is recommended
Despite all this, fasting during Ramadan may provide enduring benefits, it can provide an opportunity for a better lifestyle, facilitate weight loss and smoking cessations.
For our Muslim brothers and sisters who choose to fast, Ramadan may help to strengthen the treatment alliance between patient and doctor, and may provide an opportunity to improve diabetes management, with a focus on self-care and the regulation of medication and meal timings.
We wish you a successful and safe Ramadan from the Medlux International team. Ramadan Mubarak!