How to manage your diabetes during Ramadan

Even when fasting, regular dietary recommendations should be followed. Continue trying to eat at least five fruits and vegetables a day. Rahima Alani

For Muslims with diabetes, the fast during Ramadan can present a challenge in day to day management of the condition. In this article, Dr Hala Alsafadi offers tips on staying safe.

What happens to your body during fasting?

During a fast, at about eight hours after your last meal, your body starts to use energy stores to keep your blood glucose (sugar) levels normal. For most people this is not harmful, but if you have diabetes, your body cannot use the glucose as well as it should. With diabetes – especially if you take certain tablets or insulin – you are at risk of hypoglycaemia (low blood glucose levels).

Another challenge that can occur if you have diabetes, is the risk of high sugars following the larger meals that you eat before and after fasting (at sehri and iftar), which can lead to health problems in the short and long term.

Understanding the risks

Your diabetes nurse or doctor will be able to assess the risks associated with fasting and recommend changes to the type, dose and timing of your medication to keep you safe during the fast. It is important to realise that care is highly individualised and that the management plan will differ for each specific person.

Fasting is not recommended in the following situations:

• Type 1 diabetes;
• Frequent hypoglycaemia or hypo unawareness (i.e. not being aware of it when you're having low blood sugar);
• Diabetic ketoacidosis within the past six months;
• Hospital admission for very high blood glucose within the last six months;
• Severe hypoglycaemia (low blood glucose) in the past six months;
• If you have poor control of your diabetes – HbA1c is greater than 75 mmol/mol (9%);
• If you have complications of diabetes such as problems with kidneys, heart or poor vision;
• If you have an acute illness, including a diabetic foot infection or foot ulcer;
• If you are pregnant.

Being safe whilst fasting

It is important that you speak to your diabetes team before fasting and in particular if you are on tablets or insulin. To be able to fast safely, you should test your blood glucose levels regularly.

Blood glucose monitoring, blood sampling, and injections do not invalidate the fast. You need to test your blood glucose two to four hours after you begin fasting and then a few times during the day. You need to break your fast if your blood glucose levels fall too low or rise too high. Generally, levels below 4 mmol/L (or 70 mg/dL), or above 16 mmol/L (or 300 mg/dL) are considered unsafe. It is very important, however, that you discuss with your diabetes care team to find out what levels are safe for you.

Diet and exercise advice

Dates and milk are a traditional choice for breaking the fast. However, for people with diabetes, remember that dates are rich in rapidly absorbed sugar, so it's best to limit how much you eat. The common practice of ingesting large amounts of foods rich in carbohydrate and fat, especially at the sunset meal, should be avoided.

Distributing calories over two to three smaller meals during the no-fasting interval – rather than eating one big meal – may help to prevent excessive hyperglycaemia (high blood sugar) after you eat.

Symptoms felt with high blood sugar and low blood sugar are sometimes the same, making it difficult to recognise the actual condition.

General healthy diet advice should be followed, including eating at least five fruits and vegetables a day. It is recommended you choose foods that help promote a slow steady rise in your blood sugar (often called low Glycaemic Index foods or complex carbohydrates) at dawn, such as whole grain bread, whole grain low sugar cereals, beans and lentils. These foods are slowly digested, which can help to maintain your blood glucose levels and may make you feel less hungry.

Adequate fluid intake (water and sugar-free drinks) when breaking the fast is crucial to prevent the risks of dehydration, kidney failure, and blood clots. Physical activity is encouraged, but talk to your diabetes care provider to discuss whether or not you should make modifications to your workout schedule or the intensity of your exercise based on your new eating routines.

Advice for people with type 1 diabetes

The general advice for those with type 1 diabetes is that they should not fast; however, in some circumstances, they may be able to come up with a safe plan with the help of their diabetes health care providers. Prior to Ramadan, they should receive adequate training and education, particularly with respect to self-management and insulin dose adjustment.

Advice for people with type 2 diabetes

If your diabetes is managed by diet or certain oral medications such as metformin or pioglitazone, you may be able to fast safely. If you are on any other tablets or injections you need to speak to your diabetes team as the dose and timing of your medication should be reviewed and adjusted.

Blood pressure and cholesterol treatment

Dehydration and a tendency towards low blood pressure may occur with fasting during Ramadan, especially if the fast is prolonged. Talk to your doctor about ways to decrease your risk and about whether or not you will need to make any changes to your other medications.

Adapted from an article originally published in the Diabetes Research & Wellness Foundation monthly newsletter Diabetes Wellness News (with permission).