RAMADAN: Information for Healthcare Professionals
The holy month of Ramadan is an important part of the Muslim calendar, during which daylight fasting is practiced. Many Muslims with diabetes are exempt from fasting, however some will still participate, this can cause a challenge for healthcare professionals to support and facilitate safe fasting during Ramadan.
Census data indicates there are approximately 2.7 million Muslims in the UK with a significant proportion diagnosed with diabetes. It can often be difficult for these patients to know how to best manage their health whilst fasting. Equally, many may be suffering from other health conditions or may be taking additional medicines for their treatment.
Therefore, providing an individualised service tailored to the needs of the patient is paramount (South Asian Health Foundation. Ramadan: Diabetes and fasting tool kit).
This page provides some tips for healthcare professionals on preparing people with diabetes for Ramadan.
Exemptions
People with the following health circumstances may be exempt from fasting during Ramadan:
Anyone who may be putting their health at serious risk by fasting during Ramadan
Patients with diabetes using insulin and/or medication
Patients who have a diabetes-related complication e.g. retinopathy, nephropathy or neuropathy
Patients with an out-of-range HbA1c
Children (under the age of puberty)
The elderly or frail
Those who are sick or have a certain health or mental health condition
Those with learning difficulties
Those who are travelling long distances where the journey may be difficult
Pregnant, breastfeeding or menstruating women
According to Islamic practice, patients who cannot fast can compensate by either offering charity or fasting at other times of the year when their health is better, or fasting during winter when the days are shorter. It is also worth pointing out that patients who cannot fast can still take part in the nightly Taraweeh prayers, or reading the Qur’an throughout the month of Ramadan. For further information, patients should be advised to speak to their local Imam. (South Asian Health Foundation).
Risk
The following risks for Muslims with diabetes are increased during Ramadan;
Hypoglycaemia
Hyperglycaemia
Diabetic Ketoacidosis
Dehydration
Thrombosis (secondary to dehydration)
Hypotension and falls (secondary to dehydration)
For more information on this, please refer to the EDEN Safer Ramadan eLearning Module.
Preparing for Ramadan
Planning and preparing for fasting can support your patient to have a safer Ramadan. It is important to identify whether:
The patient will fast this year
Their diabetes medication will need altering
The patient plans to make some changes to their food choices
If physical activity will be undertaken during Ramadan
(Leicester Diabetes Centre, 2018).
Pre-Fast Assessment
Assessment and advice should be undertaken two months prior to Ramadan
Use a shared decision making approach whilst considering whether an individual should fast or not
Factors to assess for an individual with diabetes include:
Type of diabetes
Medications used to manage their diabetes
Hypoglycaemic risk
Complications and comorbidities
Social and work circumstances
Previous Ramadan experience
People with diabetes who choose to fast should be trained to:
Monitor blood glucose levels (inform that finger pricking does not break the fast)
Recognize symptoms and signs of hypoglycaemia and how to reduce the risk
(Ibrahim et al, 2015. Leicester Diabetes Centre, 2018)
Blood Glucose Monitoring
Please inform the patient that checking blood glucose levels does not break the fast.
Patients with diabetes should be advised to check their blood glucose levels at the following occasions during fasting:
Pre-dawn meal (suhoor)
Morning
Midday
Mid-afternoon
Pre-sunset (iftar)
2-hours after iftar
At any time when there are symptoms of hypoglycaemia/hyperglycaemia or feeling unwell
(Ibrahim et al, 2015. Leicester Diabetes Centre, 2018. IDF-DAR)
Click here to download a PDF version of this infographic.
Breaking the fast:
Patients must be prepared to break their fast if they have:
Blood glucose <4 mmol/L
Blood glucose >16.6 mmol/L
Symptoms of hypoglycaemia, hyperglycaemia, dehydration or acute illness
Re-hydration is important when breaking fasts for people living with diabetes., using sugar-free, caffeine-free drinks.
Hypos
There is an increased risk of severe hypos during Ramadan (Salti et al, 2001)
If a patient experiences hypoglycaemia, they should break the fast and monitor blood glucose every 4 hours
Preferred antidiabetic drugs during Ramadan are those with a low risk of hypoglycaemia
Insulin therapy is recommended to be avoided during Ramadan due to the increased risk of hypoglycaemia
(Ibrahim et al, 2015. Leicester Diabetes Centre, 2018)
Hyperglycaemia
There is an increased risk of severe hyperglycaemia during Ramadan. (Salti et al, 2001)
Hyperglycaemia can cause dehydration which can be exacerbated by active jobs, hobbies and hot weather.
Dehydration increases the risk of hypotension, falls and thrombosis.
The meals eaten during Ramadan often contain large amounts of fatty and sugary foods, which can negatively impact blood glucose levels
Over-indulgence (feasting) in high-fat, high-carbohydrate, calorie-rich foods, after completion of the fasting period, may cause peaks of hyperglycaemia
(Kalra et al, 2015)
Diet
An individual’s religion and culture should be considered when preparing their diet plan
Diet during Ramadan should be comparable with that followed for the rest of the year
(Al-Arouj et al. 2010)
Often the type or amount of food eaten changes during this month
This can have an effect on blood glucose levels and weight
Making healthy food choices can minimise the effect on blood glucose levels and weight
(Leicester Diabetes Centre, 2018)
Common negative eating habits that may develop during Ramadan include:
Eating lots of highly processed carbohydrates and sugar between iftar and suhoor causing hyperglycaemia and weight gain
Eating quickly, leading to over-eating (satiety signals take around 30 minutes to reach the brain)
Consuming large portions of high glycaemic index (GI) carbohydrates at suhoor causing postprandial hyperglycaemia
Frying food, which is particularly unhealthy, especially when using trans-fat margarine or oils rich in saturated fat (e.g. palm oil and coconut oil)
Advice:
Meals should be balanced
Sugar, highly processed grains or caffeine should be avoided
Adequate hydration should be maintained by drinking water and non-sweetened beverages
Suhoor should be taken as late as possible:
Begin iftar with plenty of water to overcome dehydration and 1–2 dried or fresh dates to raise blood glucose levels (IDF-DAR)
Exercise
Physical activity
Being active or inactive will have an effect on blood glucose level and weight
Advise a patient to check their blood glucose levels and carry hypo treatment whilst being active
Some activities are more likely than others to cause ‘hypos’ (low blood glucose levels)
It may be safer to be active after eating
(Leicester Diabetes Centre, 2018).
Light/moderate exercise is encouraged in Ramadan.
The taraweeh (night prayer) is considered to be part of an individual’s exercise regime as it entails standing, sitting, bowing and prostrating.
Excessive or strenuous exercise should be avoided during Ramadan.
(South Asian Health Foundation, 2018).
Whilst fasting, exercise will increase the risk of hypos, especially if people are on treatment with insulin and sulfonylureas.
Exercise can also increase the risk of dehydration, especially if people are on SGLT-2 inhibitors and diuretics.
During Ramadan there are special additional nightly prayers ‘Taraweeh prayers’ held in local Mosques.
These prayers have exertional activity which increases the risk of hypos and dehydration
Patients with diabetes undertaking Taraweeh prayers should be advised to:
Carry a glucose treatment and water
Eat the evening meal before praying
Include starchy carbohydrate foods in the meal in order to prevent hypoglycaemia
(South Asian Health Foundation).
Smoking
People with diabetes who smoke have an increased risk of heart disease
During Ramadan, Muslims must abstain from smoking (including Vaping, Shisha and any form of tobacco consumption) during the fasting period
As Ramadan is a time of self-control and discipline, it is a good time to give up smoking.
As a healthcare professional it is important to provide advice on quitting or alternatively direct to locally available services
(South Asian Health Foundation)
Diabetes Medications
In some cases, diabetes medication can cause low blood glucose levels
The amount and timing of medication can be changed to reduce the risk. There are diabetes medications available which make low blood glucose levels less likely to happen
Medication can also be changed to ensure that blood glucose levels do not rise too high
(Leicester Diabetes Centre, 2018).
Oral & Injectable Therapies:
The following medication does not require dose adjustment during Ramadan:
Dipeptidyl peptidase-4 (DPP-4) inhibitors.
Glucagon-like peptide-1 receptor agonists (GLP-1 RAs): as long as they have been appropriately dose-titrated (6 weeks before).
Sodium-glucose co-transporter-2 (SGLT2) inhibitors: However the patient may be at increased risk of dehydration which may lead to DKA during Ramadan.
Further guidance for both SU and Metformin can be found via e-Learning courses from EDEN Diabetes
Insulin:
Some insulin treatments need adjusting if the patient wishes to fast (see graphic).
Pre-mixed insulin is not recommended for use in Ramadan due to the increased hypoglycaemia risk and inflexibility of regime. Where possible change to a long acting basal insulin. However, if patient refuses to change the guidance below should be used with caution.
Basal/Bolus insulin therapies:
The use of long and rapid-acting insulins are superior to human (NPH) and Pre-Mixed insulins for reducing the risk of hypoglycaemia.
In some patients a larger insulin dose may be needed after a large evening meal
Pre-Mixed insulin therapies::
Most prescribed insulin type for Muslim people with type 2 diabetes.
Switching from 30:70% to 50:50% during the evening meal has shown to reduce HbA1c and risk of hypoglycaemia.
Trial fasting for three consecutive days to help detect hypoglycaemia risk and guiding self-titration.
People with type 1 diabetes especially should not stop their insulin during fasting.
(Ibrahim et al, 2015)
Post Ramadan Advice
Eid ul-Fitr:
Post fast 3 day festival, marks the end of Ramadan.
Patients should be made aware of the risk of over indulgence:
Feasting in high-fat, high-carbohydrate, calorie-rich foods may cause peaks of hyperglycaemia.
(Kalra et al, 2015)
Post-Fast Debriefing:
A post-Ramadan follow-up is advisable in order to:
Discuss the individuals biopsychosocial health and quality of life during the fasting period
Create an action plan in order for the patient to cope better with future fasts (Kalra et al, 2015)
Discuss medication and regimen readjustments
It should be stressed that one safe fast does not automatically make a patient low risk for the next year as diabetes is a progressive disease.
Ramadan-focused education
Studies have demonstrated that Muslims who see their healthcare professional before Ramadan and receive Ramadan-focused education have significantly fewer hypoglycaemic episodes.
Ramadan-focused education includes topics such as:
Risks
Glucose monitoring
Nutrition
Exercise
Medication
Hypoglycaemia and when to break fasts
Please be aware that some patients may prefer to discuss fasting with their Imam rather than a healthcare professional.
Resources
Access the 2020 Ramadan ADA/ EASD guideline here: https://drc.bmj.com/content/bmjdrc/8/1/e001248.full.pdf
References:
Hanif W, Patel V, Ali SN, Karamat A, Saeed M, Hassanein M, Syed A, Chowdhury TA, Farooqi A, Khunti K. (2020). The South Asian Health Foundation (UK) Guidelines for Managing Diabetes during Ramadan: 2020 Update. Available at: https://static1.squarespace.com/static/5944e54ab3db2b94bb077ceb/t/5e84cf44b2c53d0e6dc978b1/1585762118753/2020_Update_SAHF_v1.pdf (Accessed: 09/04/2020).
South Asian Health Foundation (2018). Fasting with Diabetes during Ramadan. Available at: https://static1.squarespace.com/static/5944e54ab3db2b94bb077ceb/t/5ae946b603ce640346ccd777/1525237433533/Ramadan_SAHF_2018.pdf (Accessed: 14/04/2020).
Leicester Diabetes Centre (2018). A Safer Ramadan Handbook for People with Type 2 Diabetes.
Salti, I.; Benard, E.; Detournay, B. et al. (2001) A population-based study of diabetes and its characteristics during the fasting month of Ramadan in 13 countries: results of the epidemiology of diabetes and Ramadan (EPIDIAR) study. Diabetes Care 27 p 2306-11
Ibrahim, M; Al Mgd, MA; Annabi, FA; Assaad-Khalil, S; Ba-Essa, EM; Fahdil, I; Karadeniz, S; Meriden, T; Misha’l, AA; Pozzilli, P; Shera, S; Thomas, A; Bahijri, S; Tuomilehto, J; Yilmaz, T; Umpierrez, GE (2015). ‘Recommendations for management of diabetes during Ramadan: update 2015’. BMJ. 3. Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4477152/ (Accessed: 06/11/2019).
Al-Arouj, M.; Assaad-Khalil, S.; Buse, J. et al. (2010) Recommendations for management of diabetes during Ramadan: Update 2010. Diabetes Care 33 p 1895-902.