What is Ramadan?
Ramadan is the holy month in which Muslims all over the world fast from dawn to sunset for 30 days. This year, Ramadan falls on the 13th of April 2021 until 12th May 2021. Considered one of the five pillars of Islam, healthy Muslims are obligated to fast during this period. However, there are exemptions to who is considered fit and healthy for fasting during Ramadan, this includes people living with diabetes.
Living with Diabetes & Ramadan Fasting
It is estimated that there are 148 million Muslims with diabetes worldwide. In Malaysia, 1 in 5 adults is living with diabetes. Muslims with diabetes may be looking to observe this holy month as fellow Muslims. However, there are risks that need to be acknowledged before anyone with diabetes considers fasting during Ramadan. Firstly, let’s take a look at the two different types of diabetes:
Type 1 diabetes
Type 1 diabetes or previously known as juvenile diabetes or insulin-dependent diabetes is a chronic condition where the pancreas is unable to produce insulin or can only create a limited amount of it. Insulin is an essential hormone made by the pancreas which helps the human body to absorb glucose – the primary source of energy for the human body.
Without insulin, the glucose level in the body can get too high and cause short term issues such as dehydration, weight loss and ketoacidosis. In the long run, high glucose levels can also cause damage to vital organs. Typically, Type 1 diabetes is diagnosed in children and teens but it can also be diagnosed in adults.
Type 2 diabetes
Type 2 diabetes or previously known as adult-onset diabetes or non-insulin-dependent diabetes is the more common type of diabetes with over 90% of individuals being diagnosed with this type of diabetes. Type 2 diabetes occurs when the body becomes resistant to insulin or is unable to produce enough of it and utilise the insulin effectively.
Type 2 diabetes is usually diagnosed in adults over 40 years old and when compared with Type 1 diabetes, the symptoms of Type 2 diabetes are more easily missed. Both types of diabetes are currently incurable but completely manageable.
Risk Associated with Ramadan Fasting For Diabetics
On average, in Malaysia, Muslims fast for 13 hours a day and this decrease in food consumption is a well-known risk for hypoglycemia. Hypoglycemia is a dangerous condition for diabetes where the level of glucose drops below normal. A study found that during Ramadan, the rates of severe hypoglycemia in Type 1 and Type 2 diabetes were higher than before Ramadan. After breaking the fast, individuals with diabetes are also at risk of increasing the blood glucose level in the body too quickly.
Hyperglycemia is a clinical situation where the blood sugar level in the body reaches an excessive level or when the blood glucose is greater than 125 mg/dL (milligrams per deciliter) while fasting. Higher rates of severe hyperglycemia have been recorded in individuals with Type 1 and Type 2 diabetes during the month of Ramadan. Furthermore, a study shows that during this time, the risk of severe hyperglycemia is 3.2 times higher for individuals with Type 1 diabetes and five times higher for individuals with Type 2 diabetes.
Since fasting during Ramadan also means zero fluid intake during the day, this can easily lead to dehydration. It can then be further exacerbated by rigorous activities during the day and high levels of perspiration.
Diabetes Management During Ramadan
Anyone with diabetes intending to fast this month must get the proper guidance on diabetes management. Individuals taking insulin and metformin are required to make alterations to their medication schedules.
- Blood sugar levels are to be tested more regularly during Ramadan.
- Individuals must take note of the symptoms of hypoglycemia and hyperglycemia
- Always have a testing kit ready in case there is a noticeable difference in blood sugar level in the body.
- If you are taking blood glucose-lowering medication, make sure you have a form of quickly absorbed sugar with you.
- See below for which foods are good options for eating at Iftar (the break of fasting).
Medication adjustments during fasting
Before making adjustments to existing medication, it’s important to talk to a doctor or healthcare professional and get their guidance. For people with diabetes, it is worth noting that measuring blood glucose and injecting insulin does NOT invalidate a fast.
Metformin is a medication used to help lower blood sugar levels by improving how the human body deals with insulin. It is commonly used to treat type 2 diabetes. If you have been prescribed this drug for diabetes and would like to fast this Ramadan, here is a guideline on how to manage your doses during the fasting month.
When to break the fast?
Individuals with diabetes should immediately break their fast if:
- Blood glucose level is lower than 70 mg/dl (3.9 m mol/L). Re-check within one hour if blood glucose is in the range of 70-90 mg/dl (50- 3.9 m mol/L)
- Blood glucose level is higher than 300 mg/dl (16.6 m mol/L)*
- Symptoms of hypoglycemia, hyperglycemia or dehydration are present
- Ensure a healthy and balanced diet throughout the month
- Eat low glycaemic index, high fibre foods that release energy slowly before and after fasting, like whole-wheat bread, beans and rice
- Ensure your meals are well-balanced, with 45%-50% carbohydrates, 20%-30% protein and less than 35% fat
- Avoid food high in sugar,salt, saturated fat during sahur and during iftar
- Use less oil while cooking
- Have sahur or the morning meal as late as possible
- Start iftar with plenty of water to combat dehydration and enjoy a small piece of fruit or date to safely raise blood glucose levels.
Alternative to Fasting During Ramadan
Ultimately, fasting is a deeply personal decision. If individuals do decide to not fast during Ramadan for medical reasons, there are other ways to make the most out of the holy month. Charitable giving is an important part of Islam and is emphasised even more during the month of Ramadan. Considered the month of generosity and mercy, one way to observe the holy month is by giving donations to food banks, mosques and the local community. Additionally, fasting during Ramadan has always been more than just refraining from eating and drinking and another way to observe Ramadan is to refrain from any wrongdoings during the holy month.
We at Homage hope you have a safe and blessed Ramadan with your loved ones. May this holy month bring joy to you and your family. Ramadan Mubarak!
- Al-Arouj, M. et al. (2005) “Recommendations for management of diabetes during Ramadan,” Diabetes care, 28(9), pp. 2305–2311.
- Hyperglycemia: Causes, symptoms, treatments & prevention (no date) Clevelandclinic.org. Available at: https://my.clevelandclinic.org/health/diseases/9815-hyperglycemia-high-blood-sugar (Accessed: April 16, 2021).
- Metformin oral: Uses, side effects, interactions, pictures, warnings & dosing – WebMD (no date) Webmd.com. Available at: https://www.webmd.com/drugs/2/drug-11285-7061/metformin-oral/metformin-oral/details (Accessed: April 16, 2021).
- Murugappan, R. (2020) “A diabetic’s guide to fasting during Ramadan,” Toronto star, 29 April. Available at: https://www.thestar.com.my/lifestyle/health/2020/04/29/diabetics-fasting-this-ramadan-here039s-a-clinically-tested-meal-plan-for-you (Accessed: April 16, 2021).
- V, R. A. and Zargar, A. H. (2017) “Diabetes control during Ramadan fasting,” Cleveland Clinic journal of medicine, 84(5), pp. 352–356.