Ramadan
Ramadan is the Holy Month for Muslims, a time of worship, self-discipline, austerity and charity. During Ramadan, there are alterations to mealtimes and the daily routine, and special traditional foods are eaten.
Fasting is necessary for all healthy adult Muslims, with no food or water consumed between dawn and sunset. Muslims with diabetes can be exempt from fasting, but you may wish to fast nonetheless. Fasting can cause problems for people with diabetes, as your blood glucose levels are closely linked to your diet, the timings of your meals and your medication.
The Qur’an allows you not to fast if you have an illness or medical condition. You could consider donating some money to charity as an alternative means of participating in Ramadan. But if you really want to fast, make sure you can do it safely.
If you are in any doubt about how you should manage your diabetes while you fast, you should talk to your diabetes care team. There may be circumstances when you will be advised not to fast for health reasons.
Group 1: if you manage your diabetes with diet and exercise
If you manage your diabetes with diet and exercise and don’t take any medication, as long as you continue to be careful with your diet, you can fast safely during Ramadan. If you are overweight, you may lose weight during Ramadan, which will help you improve the way you control your blood glucose levels. The following tips will be helpful:
- Divide your daily food into two meals, Sehri and Iftar.
- Have some starchy food such as cereals, basmati rice, chapatis or naan at every meal.
- Have plenty of fruit, vegetables, dhal and yoghurt.
- Eat only small amounts of sweet foods such as ladoo, jelaibi or burfi.
- Avoid fatty fried foods such as samosa or pakora.
- Stick to low-calorie or ‘diet’ drinks or, better still, water. Drink plenty of fluid.
You may feel tired when fasting during Ramadan, so although it is important that you continue your daily activity and prayer, try to rest at some point in the day.
Group 2: if you manage your diabetes with diet, exercise and tablets
It is important that you follow the same guidelines as for people in Group 1 regarding diet and rest.
The advice for fasting will vary slightly depending on what diabetes medication you take. You may need to adjust your medication, depending on your symptoms and blood glucose levels. You should discuss any changes to your medication with your diabetes care team.
If you take metformin or acarbose tablets and feel unwell while you are fasting, you can consider stopping them, reducing the dose or changing the timing of when you take them. If you continue to take them, the largest dose should be taken at Iftar, so that they work when you are eating.
If you take sulphonylurea tablets or prandial glucose regulators, be aware that these can cause hypoglycaemia when you are fasting, which could make you feel ill. They should not be taken during fasting hours but you may take a dose when you are eating, e.g. at Iftar.
Pioglitazone tablets do not cause hypoglycaemia when taken alone and are usually taken once a day in the morning. If you feel unwell when you are fasting, you may wish to take them at Iftar.
DPP4 inhibitors (also known as gliptins) generally do not cause hypoglycaemia on their own. In addition, as they are taken once daily, you can continue to take them as normal, or, if it is easier, you can take them with food, e.g. at Iftar.
SGLT2 inhibitors generally do not cause hypoglycaemia on their own so you can continue to take them as normal, take a reduced dose or, if it is easier, take them with food, e.g. at Iftar.
Non-insulin injections do not cause hypoglycaemia on their own so it may be possible to continue to take these as long as you monitor your blood glucose levels closely. They can, however, cause nausea. Whether or not you can continue with these injections will depend on your blood glucose levels and symptoms.
If you are in any doubt at all about what to do with your tablets or injections when fasting, discuss it with your diabetes care team.
Testing your blood glucose when taking tablets and fasting
When you take tablets that can cause hypoglycaemia, it is a good idea to check your blood glucose more often when fasting to make sure that the level is not rising too high (more than 10) or dropping too low (less than 4).
If your results worry you and you are unsure about what to do, contact your diabetes care team for advice.
Group 3: if you manage your diabetes by taking insulin (with or without tablets)
It is important that you follow the same guidelines as for people in Group 1 regarding diet and rest.
If you manage your diabetes with insulin, it is vital that you know what to do when fasting to avoid hyperglycaemia (more than 10) or hypoglycaemia (less than 4). You must check your blood glucose frequently to make sure that it is staying within a normal range.
In general, you will need much less insulin when you are fasting and will need more during the hours when you are eating. If you do not adjust your insulin regime you will be at risk of hypoglycaemia during fasting hours.
Quick-acting insulin
Quick-acting insulins taken in combination with long-acting insulins provide a more flexible insulin regime, making it easier to alter the doses and change the timings of your injections. Your diabetes care team may advise you to change to a quick-acting insulin, so that you inject only when you are eating.
Intermediate and long-acting insulin
Intermediate and long-acting insulins are often used on their own or in combination with quick-acting insulins. The dose of long-acting insulin may need to be reduced if you are fasting.
Pre-mixed insulin
Pre-mixed insulins are not usually recommended during periods of fasting. If you do continue to use these insulins, it is likely that you will have to adjust the timing and doses so that you are always taking your insulin in conjunction with eating.
You will need to discuss any changes to your insulin regime with your diabetes care team, so be sure to contact them for advice well in advance of the next Ramadan.
Hypoglycaemia
If you have a hypoglycaemic episode (a ‘hypo’) while you are fasting, it is essential that you break your fast otherwise your hypoglycaemia may get worse and you could fall into a coma.
You should always be alert for the following symptoms and ask friends and family to look out for the signs too, as you may not always be aware of them yourself.
- Sweating
- Shaking
- Palpitations
- Double vision
- Hunger pangs
- Slurred speech
- Odd behaviour
Treatment
You should take some rapid-acting carbohydrate, such as full-fat Coke or four or five jelly sweets (be sure to check that they are halal). Then take some slow-acting carbohydrate, such as a sandwich or chapati, to keep your blood glucose levels up. Keep checking your blood glucose every ten minutes, and try to work out what caused your hypo:
- Was it because you fasted and didn't change your diabetes treatment?
- Was it because you were doing exercise or physical activity and not resting?
More information on hypoglycaemia and how to treat it can be found here.
Useful resources
The Muslim Council of Britain website: www.mcb.org.uk
