How to help patients with diabetes safely observe Ramadan
One of the most sacred traditions of Ramadan, the holiest month of the year for the world’s 1.6 billion Muslims, which begins May 6 and ends June 4, is fasting from food and drink during the approximately 12 to 16 hours between suhoor (right before dawn) to iftar (immediately following sunset). For patients with diabetes, this can put observing their faith in conflict with their health considerations.
Muslims whose fasting could aggravate a chronic condition such as diabetes are granted an exception from the tradition. Regardless, the decision for the estimated 90 million Muslims worldwide with diabetes to fast or not “can be hard and confusing,” Luma Ghalib, MD, a diabetes specialist at the Ohio State University Wexner Medical Center told Healio Primary Care Today.
“Although patients with diabetes are generally aware of the general risk of hypoglycemia and hyperglycemia, they may lack the insight of their overall health condition, kidney function and the exact mechanism of their medications,” Ghalib continued.
Data indicate that some Muslims with diabetes fast despite the potential health risk. A study in 13 countries found that of 1,070 people with diabetes 42.8% of patients with type 1 diabetes and 78.7% with type 2 diabetes fasted during Ramadan.
The International Diabetes Federation guidelines provide a way to gauge who should fast and who should not: the high risk group with severe hypoglycemia unawareness, recent hospital admission, advanced kidney disease should not fast. The majority of patients with type 2 diabetes on pills are categorized as moderate-to-low risk and it should be considered safe for these patients to fast. All patients with diabetes are encouraged to self-monitor blood glucose levels.
“Those who decide on fasting must be aware of all the potential risks associated with fasting and must have close medical supervision. A Ramadan study using [continuous glucose monitoring] found that some patients experienced significant periods of hypoglycemia while fasting, without being aware of the problem,” the International Diabetes Federation wrote.
Ghalib said clinicians should work with their patients who intend to fast on developing what she called a “medication action plan.”
Mohamed H. Ahmed, of the National Health Services Foundation Trust in Buckinghamshire, England and colleagues published an overview in the Journal of Family Medicine and Primary Care of what such a plan could entail.
Patients with type 1 diabetes should receive an injection of rapid or regular insulin, and a single injection of insulin glargine “any time during the two meals.” These researchers also provided guidance for patients with type 2 diabetes:
- Users of insulin glargine can safely use metformin.
- Users of metformin should receive two-thirds of the daily dose before iftar and the remainder before sunhoor.
- Users of repaglinide can use it by itself or together with other medications that reduce the risk for postprandial hyperglycemia.
- Users of pioglitazone do not need any modifications.
- Users of a sulfonylurea can use glipizide as indicated; users in whom a sulfonylurea induced hypoglycemia should switch to a DPP-4 inhibitor.
“Patients are advised to test their blood glucose levels regularly throughout the fasting period. Most importantly, glucose levels should be checked at any time when symptoms of hypoglycemia are recognized. All patients should comprehend the dangers of low and high blood glucose levels, know when to break the fast, and must not fast if they are unwell,” the International Diabetes Foundation also wrote.
Heba Abolaban, MD, of the Massachusetts Department of Public Health, and Ahmad Al-Moujahed, MD, PhD, MPH, of the department of ophthalmology at Harvard Medical School, noted that fasting should never be considered the equivalent of complete starvation.
“Patients should be advised to eat healthy balanced diet intwo or three small meals, between iftar and suhoor rather than one large meal to avoid postmeal hyperglycemia,” they wrote in Avicenna Journal of Medicine.
Ghalib offered examples of the foods and beverages that patients with diabetes can consume that allow them to remain true to their faith and maintain their health during Ramadan.
“Those who intend to fast should devise a plan of well-balanced meals with foods that are rich in protein. Patients with diabetes should specifically try to cut back on carbohydrates and to choose high complex carbs rather than simple carbs. White bread and high sugary drinks like soda and fruit juice should be avoided and be replaced with whole grains, fruits and fibers. While dates are a good source of potassium, they have sugar, so advise patients to be careful on how many they can eat,” she said.
Abolaban and Al-Moujahed advised on symptoms that clinicians can advise their patients with diabetes and these patients’ family members to watch for.
“Patients should check their blood glucose levels multiple times during the day and break their fasting immediately if their blood glucose level is 70 mg/dL or less or 300 mg/dL or more, or if they become symptomatic of hypoglycemia or hyperglycemia,” they wrote.
Ghalib noted that not every patient with diabetes is predisposed to these risks.
“Patients who have type 1 diabetes, recurrent hypoglycemia and already have kidney disease are at higher risk for these complications,” she said.
Abolaban and Al-Moujahed advised that patients with diabetes be reminded of treatments for both hypoglycemia and hyperglycemia during Ramadan.
Ghalib noted that not all Muslims will volunteer their fasting plans, making it imperative that the clinician ask about it.
“It’s important to know what your patients intend to do for Ramadan and that you be supportive and understanding of that decision without being authoritative. Use the opportunity to learn what you can about Ramadan. Knowledge is power.” – by Janel Miller
For more information:
The American Diabetes Association guidelines on Ramadan can be found at:
The International Diabetes Foundation guidelines on Ramadan can be found at:
Aboldan H and Al-Moujahed A. Avicenna J Med. 2017;doi:10.4103/ajm.AJM_76.17.
Ahmed MH, et al. J Family Med Prim Care. 2017; Jan-Mar; 6(1): 11-18.
Almalki MG, et al. Clin Med Insights Endocrinol Diabetes. 2018;doi:10.1177/1179551417751611.
International Diabetes Foundation. Diabetes Res Clin Pract. 2017;doi:10.1016/j.diabres.2017.03.00.
Mayo Clinic. https://www.mayoclinic.org/diseases-conditions/hyperglycemia/symptoms-causes/syc-20373631. "Hyperglycemia in Diabetes." Accessed April 29, 2019.
Mayo Clinic. https://www.mayoclinic.org/diseases-conditions/hypoglycemia/symptoms-causes/syc-20373685. "Hypoglycemia." Accessed April 29, 2019.
NBC News. https://www.nbcnews.com/news/religion/what-ramadan-six-things-know-about-muslim-holy-month-n586426. “What is Ramadan? Six things to know about the Muslim Holy Month.” Accessed April 29, 2019.
Pew Research Center. https://www.pewresearch.org/fact-tank/2017/01/31/worlds-muslim-population-more-widespread-than-you-might-think/. "World’s Muslim population more widespread than you might think." Accessed April 29, 2019.
Salti I, et al. Diabetes Care. 2004; Oct;27(10):2306-11.
Disclosures: Ghalib reports no relevant financial disclosures. Please see the studies for those authors relevant financial disclosures.