The diabetics willing to fast during Ramadan should be educated about the risks involved and the measures to mitigate them.

1. Diabetes
and
Fasting
Dr. P.Naina Mohamed
Pharmacologist

2. Introduction
 Ramadan is the ninth lunar month of islamic
calendar year and Fasting during Ramadan is
a duty for all healthy adult Muslims.
 Children, elderly people, travelers, pregnant
or nursing women and unhealthy individuals
are exempt from fasting.
 Muslims abstain from eating, drinking, use of
oral medications, and smoking during fasting
period which falls between sunrise and sunset.
 The healthcare professionals should be aware
of potential risks associated with fasting and
appropriate measures to mitigate those risks.

3. Risks Associated with Fasting in
Diabetics
Risks Associated with
Fasting in Diabetics
Hypoglycemia
Hyperglycemia
Diabetic
Ketoacidosis
Dehydration
Thrombosis

4. Hypoglycemia
 Fasting during Ramadan, the risk of severe
hypoglycemia is increased 4.7-fold in Type 1
diabetics and 7.5-fold risk in Type 2 diabetics,
according to a largest study called EPIDIAR.
 Decreased food intake is a well-known risk
factor for the development of hypoglycemia.
 Severe hypoglycemia was more frequent in
patients who underwent dosage changes of
oral hypoglycemic agents or insulin and in
those who changed their lifestyle significantly.

5. Hyperglycemia
 Hyperglycemia may occur due to excessive
reduction of dosages of medications
assuming to prevent hypoglycemia.
 The higher intake of food and/or sugar may
also increase the risk of severe
hyperglycemia.
 The extensive EPIDIAR study showed a fivefold
increase in the incidence of severe
hyperglycemia in type 2 diabetics and
threefold increase in type 1 diabetics.

6. Diabetic ketoacidosis
 Poorly controlled type 1diabetics are at
increased risk for development of
diabetic ketoacidosis.
 The risk for diabetic ketoacidosis may also
be increased by excessive reduction of
insulin dosages assuming to avoid
hypoglycemia.

7. Dehydration
 Dehydration can be caused by prolonged
limitation of fluid intake during the ramadan
fast.
 The dehydration may become severe due to
excessive perspiration in hot and humid
climates and among individuals who perform
hard physical labor.
 Osmotic diuresis caused by hyperglycemia,
further contributing to volume and electrolyte
depletion.
 Preexisting autonomic neuropathy in
diabetics may induce Orthostatic
hypotension.
 Hypovolemia and the associated hypotension
may lead to syncope, falls, injuries, and bone
fractures.

8. Thrombosis
 Diabetes induces the contraction of the
intravascular space which exacerbate the
hypercoagulable state.
 Excessive blood viscosity associated to
dehydration may enhance the risk of thrombosis
and stroke.
 A report from Saudi Arabia suggested an
increased incidence of retinal vein occlusion in
patients who fasted during Ramadan.
 However, hospitalizations due to coronary events
or stroke were not increased during Ramadan.

9. Assessment before Ramadan
 Medical assessment and structured education
program should be done for all diabetics who wish
to fast during Ramadan.
 This assessment should take place 1–2 months
before Ramadan.
 To control the diabetics’ blood sugar, blood
pressure, and lipids, appropriate blood studies
should be ordered and evaluated.
 Specific medical advice on the risks of fasting,
should be provided to the diabetics who decide
to fast.
 During this assessment, necessary changes in diet
or medication regimen should be made.

10. Categories of risks of Diabetics
Very high risk
•Severe hypoglycemia within
the 3 months prior to Ramadan
•A history of recurrent
hypoglycemia
•Hypoglycemia unawareness
•Sustained poor glycemic
control
•Ketoacidosis within the 3
months prior to Ramadan
•Type 1 diabetes
•Acute illness
•Hyperosmolar hyperglycemic
coma within the previous 3
months
•Performing intense physical
labor
•Pregnancy
•Chronic dialysis
High risk
•Moderate hyperglycemia
(average blood glucose
150–300 mg/dl or A1C
7.5–9.0%)
•Renal insufficiency
•Advanced
macrovascular
complications
•Living alone and treated
with insulin or sulfonylureas
•Patients with comorbid
conditions that present
additional risk factors
•Old age with ill health
•Treatment with drugs that
may affect mentation
Moderate
risk
•Well-
controlled
diabetes
treated with
short-acting
insulin
secretagogue
s
Low risk
•Well-
controlled
diabetes
treated with
lifestyle
therapy,
metformin,
acarbose,
thiazolidinedio
nes, and/or
incretin-based
therapies in
otherwise
healthy
patients

11. Ramadan-focused Structured
Diabetes Education
 Many health care professionals are unable to give the
appropriate medical advice due to lack of knowledge about
the optimum management of diabetes while fasting.
 Ramadan-focused diabetes educational program should
ideally include three components:
 An awareness campaign aimed at people with diabetes, health
care professionals, the religious and community leaders as well as
the general public.
 Ramadan-focused structured education for health care
professionals.
 Ramadan-focused structured education for people with
diabetes.

12. Education for Health care professionals
 Health care professionals should be trained to deliver a structured
patient education program that includes a better understanding of
fasting and diabetes, individual risk quantification, and options to
achieve safer fasting.
 This includes the importance of glucose monitoring during fasting
and nonfasting hours, when to stop the fast, meal planning to
avoid hypoglycemia and dehydration during prolonged fasting
hours, and the appropriate meal choices to avoid postprandial
hyperglycemia.
 The educational program should include advice on the timing and
intensity of physical activity during fasting.
 It is important that use of diabetes-related medications and their
potential risk during fasting are also discussed.
 A well-trained health care professional should be able to deliver all
these components to people with diabetes either individually or in
a group session at diabetes centers, primary health care centers,
local mosques, and/or community centers.

13. Meal planning and Dietary advice
 The diet during Ramadan should be a healthy balanced diet.
 Slow energy release foods (wheat, semolina, beans, rice) and
high fibre foods (wholegrain cereals, granary bread, brown
rice; beans and pulses) should be taken before and after
fasting.
 Foods high in saturated fat (such as ghee, samosas, and
pakoras) should be minimised.
 Limit the amount of sweet foods taken at Iftar (after sunset).
 Include fruits, vegetables, dhal (lentil) and yoghurt in Iftar and
Sehri (early morning) meals.
 Try to have the meal at Sehri at the proper time just before
sunrise, not at midnight. This will spread out energy intake more
evenly and result in more balanced blood glucose when
fasting.
 Choose sugar-free drinks or water to quench your thirst.
 Avoid adding sugar to drinks.

14. Exercise
 Type 2 diabetes patients should adopt regular
light and moderate exercise.
 The patients taking sulphonylureas or insulin
should avoid rigorous exercise as the risk of
hypoglycaemia may be increased.
 Encourage patients to continue their usual
physical activity, especially during non-fasting
periods
 Tarawaih prayers (a series of prayers after the
sunset meal) should be considered as part of
the daily exercise regimen as they involve
standing, bowing, prostrating, and sitting.

15. Management of type 1 Diabetics
 Fasting at Ramadan carries a very high risk for people with type 1 diabetes.
 This risk is particularly exacerbated in poorly controlled patients and those with
limited access to medical care, hypoglycemic unawareness, unstable glycemic
control, or recurrent hospitalizations.
 The risk is also very high in patients who are unwilling or unable to monitor their blood
glucose levels several times daily.
 The Epidemiology for Diabetes Interventions and Complications (EDIC) study,
demonstrated that intensive glycemia management is protective against
microvascular and perhaps macrovascular complications and that the benefits are
long lasting.
 Very few studies have documented the safety and/or efficacy of different insulin
regimens in type 1 diabetic patients who fast during the month of Ramadan.
 A frequently used option is once- or twice-daily injections of intermediate or long-
acting insulin along with premeal rapid-acting insulin.
 A recent small study with insulin glargine suggests the relative safety and efficacy of
this agent in 15 relatively well-controlled patients with type 1 diabetes who fasted for
18 h and experienced a minimal decline in mean plasma glucose from 125 to 93
mg/dl with only two episodes of mild hypoglycemia.
 Another study in patients with type 1 diabetes using insulin glulisine, lispro, or aspart
instead of regular insulin in combination with intermediate-acting insulin injected
twice a day led to improvement in postprandial glycemia and was associated with
fewer hypoglycemic events.
 Continuous subcutaneous insulin infusion (pump) management is an appealing
alternative strategy, but at a substantially greater expense.
 The experts suggest that type 1 diabetics who are on a basal bolus regimen four
times daily should be discouraged from fasting.

16. Management of type 2 Diabetics
Metformin:
The possibility of severe hypoglycemia is minimal in patients treated
with metformin alone and they may fast safely.
2/3 of the total daily dose of metformin should be administered with
the sunset meal and the other third (1/3) before the predawn meal.
Glitazones:
As glitazones require 2–4 weeks to exert substantial
antihyperglycemic effects, they cannot be quickly substituted for
agents associated with hypoglycemia during periods of fasting.
Sulfonylureas:
Due to the risk of hypoglycemia, sulfonylureas use during
fasting is unsuitable.
With caution these agents may be used in Ramadan due to
their worldwide use and relatively low cost.
Short-acting insulin secretagogues:
One study in patients with type 2 diabetes who fasted showed that
use of Repaglinide was associated with less hypoglycemia compared
with glibenclamide.
Nateglinide has the shortest duration of action and therefore the
lowest risk of severe fasting hypoglycemia among the secretagogues.

17. Management of type 2 Diabetics
GLP – 1 agonists (Exenatide and Liraglutide ):
Exenatide can be dosed before meals to minimize appetite and
promote weight loss. It has short half-life of 2 h and it is not associated
with a substantial effect on fasting glucose.
Liraglutide can be dosed once a day, independent of meals, and is
more effective in controlling fasting glycemia.
DPP 4 Inhibitors (saxagliptin, sitagliptin, and vildagliptin):
DPP-4 inhibitors are among the best tolerated drugs for the
treatment of diabetes.
There are no specific studies of these agents during periods of
fasting.
α-Glucosidase inhibitors (Acarbose, miglitol, and
voglibose ):
α-Glucosidase inhibitors may be useful during Ramadan as
they are not associated with the risk of hypoglycemia, particularly
in the fasting state.
Insulin:
Use intermediate- or long-acting insulin preparations and a rapid-
acting insulin analog or short-acting insulin to be administered before
meals.

18. Management of Hypertension and
Dyslipidemia
 Fasting during Ramadan for prolonged hours with
excessive perspiration, may cause Dehydration,
volume depletion, and a tendency toward
hypotension.
 Hence, the dosage and/or the type of
antihypertensive medications may need to be
adjusted to prevent hypotension.
 Diuretics may not be appropriate during
Ramadan for some patients.
 Appropriate counseling should be given to avoid
foods rich in carbohydrates and saturated fats.
 The agents previously prescribed for the
management of elevated cholesterol and
triglycerides should be continued.

19. Tips for Healthcare providers
 The healthcare providers can improve the diabetes care in Muslims who
are decided to fast during Ramadan, in following ways…
 Adjust diabetic medication if needed, since the Ramadan fasting
improves diabetes by lowering the blood glucose and HbA1c.
 As the Meditation and prayers tend to lower blood pressure, adjust
the dosage of antihypertensive drugs.
 Non-porcine synthetic (human) insulin should be given in place of
Pork insulins, pork-based synthetic insulins, and beef (non-halal)
insulins which are unacceptable to devoted Muslims.
 In Ramadan, a person with type 2 diabetes can take a
sulphonylurea at the end of the fast, with the evening meal started
within 30 minutes. Advise not to miss the sehri (before sunrise) meal so
as to avoid hypoglycaemia later in the day.
 Repaglinide (NovoNorm) can be taken when a meal is eaten,
therefore no change in drug therapy will be required in Ramadan. A
meal must be eaten within 15 minutes.
 Adjust medication or advise the patients who take alternative
medicine concurrently to treat diabetes.
 Dietary tips about Glycaemic foods like khir (rice pudding) and
vermicelli Hypoglycemic foods such as karela (a vegetable), onion
and garlic should be provided to the patients.
 Counsel the patient by saying ‘to see the doctor and comply with
treatment is Prophet Mohammad's sunnat (precedent)’. To refuse
would be a sin.

20. Tips to the Diabetics
 Type 1 Diabetic patients and type 2 diabetics who require
insulin should monitor their blood glucose levels multiple times
daily.
 Inappropriate diet, over-eating and insufficient sleep are the
causes of most health problems occurring in Ramadan.
 During iftar (sunset meal), large amounts of foods rich in
carbohydrates and fats, should be avoided.
 The foods containing “complex” carbohydrates (slow digesting
foods) may be advisable at the predawn meal.
 During nonfasting hours, fluid intake should be increased.
 To avoid the risk of hypoglycemia, excessive physical activity
should be avoided.
 All patients should understand that they must end their fast
immediately, if hypoglycemia (blood glucose of <60 mg/dl [3.3
mmol/l]) occurs.
 Patients should avoid fasting on “sick days.”

21. Points to Remember
Diabetics should
discuss with
Healthcare
Professionals
Diabetics should
undergo Pre
Ramadan
Assessment
Ramadan-focused
Structured
Diabetes
Education
•Risks involved in
fasting
•Ways to mitigate
the risks
•Assessment should be
done 1-2 months
before Ramadan
•Patients’ blood sugar,
lipids and blood
pressure should be
assessed.
•Awareness campaign for all.
•Ramadan-focused structured
education for health care
professionals as well as diabetics
regarding physical activity, meal
planning, glucose monitoring,
and dosage and timing of
medications.

22. CONCLUSIONS
 Type 1 Diabetics willing to Fast during Ramadan, are at very high
risk of life-threatening complications such as severe hypoglycemia,
hyperglycemia and diabetic ketoacidosis.
 Type 2 diabetics carry less risk of Hypoglycemia and
Hyperglycemia in compared to Type 1 diabetics.
 Current evidence has proved that Type 1 and Type 2 adult
diabetics can fast during Ramadan safely after discussing with a
health care provider concerning the risks involved.
 The diabetics who insist on fasting should undergo pre-Ramadan
assessment and receive appropriate education and instructions
related to physical activity, meal planning, glucose monitoring, and
dosage and timing of medications.
 The management of children with diabetes who choose to fast
during Ramadan is a challenge for pediatrician as the majority of
guidelines and data on safety and metabolic impact of fasting are
based on practice and studies on adult population.
 If the child and family received proper education and intensive
follow up clinic during Ramadan, it is feasible for children older than
8 years with long-standing Type 1DM to safely fast during Ramadan.

23. References
 http://care.diabetesjournals.org/content/28/9/2305.full
 http://www.bmj.com/content/340/bmj.c3053?ijkey=RhP
6GwQb5TAzfiq&keytype=ref
 http://www.diabetes.org.uk/Guide-to-
diabetes/Managing-your-diabetes/Ramadan/
 http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1279173/
 http://www.diabetes.co.uk/diet/ramadan-and-
diabetes.html
 http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2909082/
 http://www.joslin.org/info/Ramadan-and-Diabetes.html

24. References
 http://www.leicestershirediabetes.org.uk/uploads/
123/documents/Ramadan%20info%20booklet%20
082012v3.pdf
 http://www.ramadan.co.uk/RamadhanHealth_Gu
ide.pdf
 http://www.sciencedirect.com/science/article/pii
/S1877593410000317
 http://www.medscape.com/viewarticle/807502
 http://www.idf.org/sites/default/files/attachments/
article_513_en.pdf
 http://www.libyanjournalofmedicine.net/index.ph
p/ljm/article/viewFile/4731/4921