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What is Ramadan?
Ramadan is the holy month for Muslims, falling in the ninth lunar
month in the Islamic calendar year. Because the timing of Ramadan
is linked to the sighting of the new moon, it takes place approximately
ten days earlier each year. This year it takes place at the end
of November. Ramadan is a period of worship, self-discipline,
austerity and charity.
Fasting is one
of the five pillars of Islam. Fasting can last up to 18 hours
a day during the summer months, with no food or drink being taken
between dawn and sunset. Fasting is obligatory for all healthy
adult Muslims. Exemption from fasting is granted to certain people,
including children under 12, the sick, the elderly, pregnant and
breast-feeding women and travellers. People with diabetes can
be exempt from fasting, and those whose diabetes is treated with
insulin or sulphonylureas may be advised not to fast because of
the risk of hypoglycaemia. Despite being exempt, people with diabetes
often exhibit a strong desire to fast during Ramadan.
Hazards of fasting during Ramadan
For those on sulphonylurea tablets or insulin the major danger
is from hypoglycaemia. However, dehydration can occur if the patient
has symptomatically uncontrolled diabetes.
Blood glucose
levels may swing from very high to very low during Ramadan, and
people who are fasting should be advised to monitor their blood
glucose carefully. In particular, they should ensure that they
are aware of the signs and symptoms of hypoglycaemia. Anyone whose
blood glucose goes below 3.5 mmol/l should break their fast and
take a sweet drink, followed by starchy foods such as bread, chapati,
naan or pitta bread.
During Ramadan
people often avoid exercise to save energy. This may account for
the sharp drop in diabetes clinic attendance that has been observed
during the holy month. Attendance should be encouraged to allow
the care team to keep a close watch on the persons diabetes
particularly if they have been advised to adjust their treatment.
Avoid making appointments for Friday as most people will wish
to attend the mosque on that day.
Changes to diet
During Ramadan there is a major change in the dietary pattern.
As well as fasting between dawn and sunset, large quantities of
sugary fluids, such as canned juices and carbonated drinks, together
with fried foods and carbohydrate-rich meals are taken during
the non-fasting hours. Sweet foods may also be specially prepared
for Ramadan.
There are only
two meals a day Sehri (early morning meal) and Iftar (break
of fast after sunset). The early meal may be at a very early hour,
eg 4am. Meal times should be defined before further advice is
given.
Longer gaps
between meals and greater amounts of foods in particular, foods
with high sugar or starch mean people with diabetes may experience
large swings in blood glucose levels during Ramadan.
The following
general dietary guidelines should help control blood glucose levels
during Ramadan:
 limit the amount of sweet foods taken at Iftar (after sunset).
Only have small amounts of sweet foods such as ladoo, jelaibi
or burfi
fill up
on starchy foods such as basmati rice, chapati or naan
include fruits, vegetables, dhal and yoghurt in your meals
at Iftar and Sehri (early morning)
try to
have the meal at Sehri just before sunrise, not at midnight. This
will spread out your energy intake more evenly and result in more
balanced blood glucose when fasting
choose
sugar-free types of fizzy drinks and cordials. Choose sugar-free
drinks or water to quench your thirst. Avoid adding sugar to drinks;
use a sweetener where needed, eg Canderel, Sweetex, Hermesetas
limit fried
foods such as paratha, puri, samosas, chevera, pakoras, katlamas,
fried kebabs and bombay mix. Measure the amount of oil used in
cooking (use 12 tablespoons for a four-person dish).
The traditional
rich foods associated with Ramadan and with the religious festival
Eid-ul-Fitr, which marks the end of fasting, may also present
a risk of weight gain for the Muslim patient with diabetes. Advising
at this time is an opportunity to educate the family with regards
to long-term, healthier dietary choices. It is important that
if healthy eating patterns are adopted they continue after Ramadan
as part of a healthier lifestyle.
Changes to treatment
Diet alone
People whose diabetes is controlled by diet alone should be able
to fast safely. However, food and drink at break of fast should
be carefully thought out, using low-calorie drinks and limiting
sweets.
Metformin
Again, these people should be able to fast safely, there being
no danger of hypos. However, they should be made aware of the
need to change the timing of their tablets during fasting.
tablets should be taken at the end of fast, ie in the evening,
in order to cover period of eating
consider
a lower dose or even stopping for duration of fast if the patient
feels unwell on Metformin
use low-calorie
drinks and limit sweets.
Sulphonylureas (including combination of Sulphonylureas
and Metformin)
if on Glibenclamide,
think about changing to quick-acting sulphonylurea (eg Tolbutamide,
Glipizide) for duration of fast, to be taken once a day before
the break of fast meal
Chlorpropamide or Glimepiride would be safe providing there
is some dose reduction to allow for their long-acting nature
Repaglinide may be particularly useful for fasting because
of its short action and it can be taken when eating and not taken
when fasting.
Insulin
People who treat their diabetes with insulin may be advised not
to fast and to discuss this with religious advisors. In particular,
people with Type 1 diabetes whose control is poor and who are
prone to ketoacidosis should be strongly advised not to fast.
For those who
do decide to fast, the most important message is not to stop taking
insulin during Ramadan. However, people need to be very careful
to make appropriate adjustments to their insulin dosage with help
from their diabetes team. The team should also negotiate with
the patient as to how long they are able to fast safely.
The following
general guidelines should be considered:
change
to Isophane only before morning meal and mainly soluble in the
evening with small dose of Isophane strongly recommend avoiding
premixed insulin during fasting. However, if the patient insists
on staying on mixed insulin, the doses should be changed so that
less insulin is given at Sehri
insulin
analogues (Lispro) are useful for fasting because they allow people
to eat immediately and are short acting
where possible,
rest during the day to avoid low blood glucose.
Questions to ask:
Have you fasted before with diabetes? What happened then?
Valuable information can be obtained from previous experience
Will you have the pre-fast meal in the morning?
Are
you prepared to break the fast if you become hypoglycaemic
and need sugar? |
Acknowledgements:
Update wishes to thank Dr Mohan Pawa, Dr Felix Burden,
Mary Burden and the team at the Leicester General Hospital Diabetes
Centre and Anne Claydon at the Newham General Hospital diabetes
team for their help in producing this fact sheet.
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