Ramadan is the holy month for Muslims, during this one month period prayer and fasting are mandatory for every healthy Muslim Individual. Though it is an exemption for people with medical condition such as diabetes still majority of them partake against the medical advice. Therefore International Diabetes Federation (IDF) in collaboration with Diabetes and Ramadan (DAR) had come up with practice guidelines to be followed by Diabetes patients during fasting period. The guidelines are set mainly to bring patient awareness and manage diabetes during fasting. Thus, empowering healthcare professionals (HCPs) to give the most up-to-date advice and the best possible support to their patients during Ramadan.
In 2001, EPIDIAR study found that 42.8% of patients with type 1 diabetes (T1D) and 78.7% of T2D fasted for at least 15 days during Ramadan. Recently, in 2010, the CREED study reported that 94.2% of patients with T2DM enrolled in the study fasted for at least 15 days, and 63.6% fasted every day. These studies indicate how important Ramadan is for every normal and diseased Muslim individual. Studies have shown that pre-Ramadan counselling reduces the incidence of hypoglycaemia, while recent reports from the UK and Pakistan showed that effective education can be given by HCPs. Therefore the keystone of diabetes management in Ramadan is patient education on glucose monitoring, nutrition, exercise, medication adjustments, risks quantification, recognition of the symptoms of complications and when to break the fast to prevent harm. The major risks are hypoglycaemia and hyperglycaemia, dehydration and the occurrence of these events increases during fasting.
A pre-Ramadan assessment and counselling with the HCP and dietician is vital for patients with diabetes who intends to fast, in order to evaluate the risks educate the patient in self-management of the condition during Ramadan and to produce a patient-specific treatment plan.Patients at high risk for hypoglycemia, poorly controlled diabetic patients (HbA1c>10%), recent hospitalization for high or low sugars, pregnant ladies with moderate to severe diabetes, comorbid conditions like moderate to severe chronic kidney disease or heart disease and with multiple diabetic complicationsshould be advised to avoid fasting. During counselling diet and drug adherence is strongly recommended.
Important dietary tips for patients with diabetes during Ramadan.
- Divide daily calories between Suhoor and Iftar, plus 1-2 snacks if necessary
- Ensure meals are well balance with 40-50% carbohydrate, 20-30% proteins, <35% fats (preferably mono and polyunsaturated)
- Include low glycemic index, high fiber foods that release energy slowly before and after fasting. eg: Granary bread, beans, rice
- Include plenty of fruits, vegetables and salads
- Minimize foods that are high in saturated fats. eg: Ghee, samosas
- Avoid sugary desserts
- Use small quantity of oil while cooking. eg: Olive, rapeseed
- Keep hydrated between sunset and sunrise by drinking water or other non-sweetened beverages, and avoid caffeinated drinks.
- Regular SMBG during Ramdanfor diabetes patients is must.
- Try to eat just before sunrise, when you commence the next day’s fast.
- Be prepared to break the fast in case of hypo- or hyperglycaemia.
- When glucose levels fall below 80 mg/dl (hypoglycemia) take 15 grams of carbohydrate in any one of these ways. 3 tea spoons of glucose powder or ½ cup of apple or orange juice or one serving of glucose gel or 3-4 glucose tablets or 5 or 6 pieces of hard candy or one tablespoon of sugar or honey, wait for 15 minutes and check the glucose levels. Then follow with a snack if the evening meal is not for more than an hour.
- Patients taking metformin, short-acting insulin secretagogues, SUs or insulin will need to make adjustments to dose and or timings to reduce the risk of hypoglycaemia while maintaining good glycaemic control.
- Oral antidiabetes drugs including incretin-based therapies, α-glucosidase inhibitors, TZDs, and DPP4 inhibitors appear to be safe and are associated with a lower risk of hypoglycaemia and may be preferable for use during Ramadan.
- SGLT2 inhibitors are probably safe but should be used with caution in some patients. More data regarding the use of SGLT2 inhibitors during Ramadan are required.
- Strict drug adherence as per the physician advice is highly recommended.
Dr. Aftab Ahmed,
MD (Internal Medicine)
Diabetologist and Senior Consultant Physician
Apollo Sugar Clinics Ltd.