Guidance of diabetes management in Ramadan

1. Diabetes in Ramadan
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Dr/AL SAYED ALSPAGH Page | 1
‫م‬‫ي‬‫ج‬‫ر‬‫ال‬‫ان‬‫ط‬‫س‬‫ش‬‫ل‬‫ا‬
‫ن‬‫م‬‫لله‬‫ا‬‫ب‬‫وذ‬‫ع‬‫أ‬
)‫ا‬‫ب‬‫ا‬‫ه‬‫ي‬‫أ‬‫ن‬‫ي‬‫ذ‬‫ل‬‫ا‬‫وأ‬‫ن‬‫م‬‫أ‬‫ب‬‫ت‬‫ك‬‫م‬‫ك‬‫ن‬‫ل‬‫ع‬
‫ام‬‫ي‬‫ص‬‫ل‬‫ا‬‫ا‬‫م‬‫ك‬‫ب‬‫ت‬‫ك‬‫ى‬‫ل‬‫ع‬‫ن‬‫ي‬‫ذ‬‫ل‬‫ا‬‫ن‬‫م‬‫م‬‫ك‬‫ل‬‫ي‬‫ق‬
‫م‬‫ك‬‫ل‬‫لع‬
‫ا‬‫م‬‫ا‬‫ب‬‫أ‬*‫ون‬‫ق‬‫ن‬‫ت‬
‫ذوذأت‬‫ع‬‫م‬‫ن‬‫م‬‫ف‬‫ان‬‫ك‬‫م‬‫ك‬‫ن‬‫م‬
‫ا‬‫ض‬‫ي‬‫ر‬‫م‬‫و‬‫أ‬‫ى‬‫ل‬‫ع‬‫ر‬‫ف‬‫س‬‫ذة‬‫ع‬‫ف‬‫ن‬‫م‬‫ام‬‫ب‬‫أ‬‫ر‬‫خ‬‫أ‬‫ى‬‫ل‬‫ع‬‫و‬‫ن‬‫ي‬‫ذ‬‫ل‬‫ا‬‫ه‬‫ت‬‫و‬‫ق‬‫ن‬‫ط‬‫ي‬‫ه‬‫ت‬‫ذ‬‫ق‬‫ام‬‫ع‬‫ط‬
‫ن‬‫كي‬‫س‬‫م‬‫ن‬‫م‬‫ف‬‫وع‬‫ط‬‫ي‬‫أ‬‫ر‬‫ي‬‫ج‬‫و‬‫ه‬‫ف‬
‫ر‬‫ي‬‫ج‬‫ه‬‫ل‬‫وأن‬‫وأ‬‫م‬‫و‬‫ص‬‫ي‬‫أ‬‫ر‬‫ي‬‫ج‬‫م‬‫ك‬‫ل‬‫أن‬‫م‬‫ي‬‫ت‬‫ك‬‫ون‬‫م‬‫ل‬‫ع‬‫ت‬
*‫ر‬‫ه‬‫ش‬‫ان‬‫مض‬‫ر‬‫ي‬‫ذ‬‫ل‬‫ا‬
‫ل‬‫ر‬‫ن‬‫أ‬‫ه‬‫ت‬‫ق‬‫ن‬‫أ‬‫ر‬‫ف‬‫ل‬‫ا‬‫ذي‬‫ه‬‫اس‬‫ي‬‫ل‬‫ل‬‫ات‬‫ي‬‫ي‬‫ت‬‫و‬‫ن‬‫م‬‫ذي‬‫ه‬‫ال‬‫ان‬‫ق‬‫ر‬‫ف‬‫ل‬‫ا‬‫و‬‫ن‬‫م‬‫ف‬‫ذ‬‫ه‬‫ش‬‫م‬‫ك‬‫ن‬‫م‬
‫ر‬‫ه‬‫ش‬‫ل‬‫ا‬‫ه‬‫م‬‫ص‬‫ي‬‫ل‬‫ق‬
‫ن‬‫م‬‫و‬‫ان‬‫ك‬
‫ا‬‫ض‬‫ي‬‫ر‬‫م‬‫و‬‫أ‬‫ى‬‫ل‬‫ع‬‫ر‬‫ف‬‫س‬‫ذة‬‫ع‬‫ف‬‫ن‬‫م‬‫ام‬‫ب‬‫أ‬‫ر‬‫خ‬‫أ‬‫ذ‬‫ت‬‫ر‬‫ن‬‫لله‬‫أ‬‫م‬‫ك‬‫ي‬‫ر‬‫س‬‫ي‬‫ل‬‫ا‬‫لا‬‫و‬‫ذ‬‫ت‬‫ر‬‫ن‬‫م‬‫ك‬‫ي‬‫ر‬‫س‬‫ع‬‫ل‬‫ا‬‫وأ‬‫ل‬‫م‬‫ك‬‫ن‬‫ل‬
‫و‬‫ذة‬‫ع‬‫ل‬‫ا‬‫روأ‬‫كي‬‫ن‬‫ل‬‫و‬
‫لله‬‫أ‬‫ى‬‫ل‬‫ع‬‫ا‬‫م‬‫م‬‫ك‬‫ذأ‬‫ه‬‫م‬‫ك‬‫ل‬‫لع‬
‫و‬‫رون‬‫ك‬‫ش‬‫ت‬)
(O you who have believed, decreed upon you is fasting as it was decreed
upon those before you that you may become righteous. [Fasting for] a
limited number of days. So whoever among you is ill or on a journey
[during them] - then an equal number of days [are to be made up]. And
upon those who are able [to fast, but with hardship] - a ransom [as
substitute] of feeding a poor person [each day]. And whoever volunteers
excess - it is better for him. But to fast is best for you, if you only knew.
The month of Ramadhan [is that] in which was revealed the Qur'an, a
guidance for the people and clear proofs of guidance and criterion. So
whoever sights [the new moon of] the month, let him fast it; and whoever
is ill or on a journey - then an equal number of other days. Allah intends
for you ease and does not intend for you hardship and [wants] for you
to complete the period and to glorify Allah for that [to] which He has
guided you; and perhaps you will be grateful(
‫م‬‫ي‬‫ط‬‫ع‬‫ال‬
‫لله‬‫أ‬‫ذق‬‫ص‬

2. Diabetes in Ramadan
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Diabetes and Ramadan:
− Ramadan is a holy month for Muslims and, as one of the five pillars of Islam.
− Fasting during this month is prescribed from dawn to sunset.
− Fasting for 29-30 days that involve refrain from intake of Food, Liquids and oral
medications.
− Depending on the season and geographic location, the duration of fasting will
vary from 12–20 hours.
− The acting of fasting during Ramadan is only obligatory to adults who are
healthy with exception of certain groups such as:
✓ Muslims with serious illness (e.g. patients with diabetes)
✓ Elderly
✓ Travelers
✓ Expecting and nursing mothers
− Although fasting during Ramadan may provide enduring benefits. Indeed,
Ramadan can provide an opportunity for a better lifestyle, facilitating weight
loss and smoking cessation, but some patients with diabetes are at particular
risk of complications from marked changes in food and fluid intake, such those
patients should be advised to not fast.
− Although exemptions exist for people with serious medical conditions,
including many with diabetes. Nevertheless, a majority of individuals with
diabetes see the fast as a deeply meaningful, spiritual experience, and most
will participate, sometimes against medical advice.
− >148 million Muslims with diabetes worldwide, >116 million patients with
diabetes worldwide may fast during Ramadan.
Patho-physiology of Fasting
In healthy individuals, feeding promotes the secretion of insulin, which is
responsible for the storage of glucose sugar in muscles and liver as glycogen.
Levels of Insulin tend to decrease during fasting as a result of the decreased
glucose levels. On the other hand, levels of catecholamines and glucagon are
increased, which stimulates glycogen degradation. After several hours of
fasting, the stores of glycogen are depleted, and increased levels of fatty acid
are released from fat cells as a result of the low circulating levels of insulin
(Fig.1).
According to a study by Felig, the transition from a fed state to a fasted state is
mediated by several hormonal, glucoregulatory, and metabolic mechanisms,
which can be divided into three stages:

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1- Post-absorptive phase, which lasts from 6 to 24 hours after the beginning
of fasting.
2- Gluconeogenic phase, which lasts from 2 to 10 days of fasting.
3- Protein conservation phase, which happens if fasting lasts beyond 10 days
Fasting due to religious reasons never exceeds 24 hours meaning that the
body rarely reaches the second and third phases.
The month of Ramadan can precipitate dramatic changes in meal schedule,
sleep patterns and circadian rhythms.
Ramadan fasting can be associated with favorable physiological changes
among healthy individuals, such as decreased body weight and favorable
changes in lipid profile.
In patients with diabetes, however, Ramadan fasting can be associated with
certain risks due to the pathophysiology that disrupts normal glucose
homeostatic mechanisms, Therefore, patients with diabetes, and in particular
those with T1DM, should seek medical advice before deciding to proceed with
Ramadan fasting.
Fig.1: Physiology of fasting in healthy individual

4. Diabetes in Ramadan
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All patients with diabetes should schedule a visit with their doctors 6–8 weeks
before Ramadan to:
A) Stratify risk and develop an individualized management plan, to include:
1) Detailed history
2) Patient’s experience during previous Ramadan
3) Patient’s ability to self-manage diabetes
B) Structure a Ramadan-focused educational program for all patients, to
include:
1) Risk quantification
2) Self-monitoring of blood glucose (SMBG)
3) Fluids and dietary advice
4) Exercise advice
5) Medication adjustments
6) When to break the fast
1- Risk Stratification of Individuals with DM before Ramadan
A) Risks associated with fasting in people with diabetes:
1) Hypoglycemia (< 70 mg/dl)
2) Hyperglycemia (>300 mg/dl)
3) Dehydration and thrombosis
4) Acute metabolic complications such as diabetic ketoacidosis (DKA)
All these risks are also aggravated by duration of fasting time, food intake
pattern, hot and humid climates.
Healthcare professionals must be conscious of the risks associated with
fasting and should quantify and stratify the risks for every patient individually
in order to provide the best possible care.
B) Risk quantification:
It has been estimated that more than 100 million people with diabetes fast
during Ramadan and this number will continue to grow.
Safety of fasting is paramount and various elements should be considered
when quantifying the risk for such patients.
Factors for risk quantification:
1) Type of diabetes. 2) Patient medications. 3) Individual hypoglycemic risk.
4) Presence of complications and/or comorbidities.

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5) Individual social and work circumstances. 6) Previous Ramadan experience
This assessment exercise must be carried out on an individual basis for each
patient looking to fast during Ramadan, and the care given must be
personalized according to the patient’s specific circumstances.
C) Risk stratification:
A new risk categorizations defined by the International diabetes federation and
Diabetes and Ramadan International Alliance (IDF-DAR) into three risk
categories: very high, high and moderate/low. Indeed, this approach matches
the essence of the religious regulations of Islam and has been approved by the
Mofty of Egypt (Table.1).
Risk category Category 1:
very high risk
Category 2:
high risk
Category 3:
moderate/low risk
Patient
characteristics
One or more of the
following:
- Severe hypoglycemia
within the 3 months prior
to Ramadan
- DKA or HNKC within the
3 months prior to
Ramadan
- History of recurrent
hypoglycemia
- History of hypoglycemia
unawareness
- Poorly controlled T1DM
- Acute illness
- Pregnancy in pre-existing
diabetes, or GDM treated
with insulin or SUs
- Chronic dialysis or CKD
stage 4 & 5
- Advanced macrovascular
complications
- Old age with ill health
One or more of the
following:
− T2DM with sustained
poor glycemic control
− Well-controlled T1DM
− Well-controlled T2DM on
MDI or mixed insulin
− Pregnant T2DM or GDM
controlled by diet only or
metformin
− CKD stage 3
− Stable macrovascular
complications
− Patients with comorbid
conditions that present
additional risk factors
− People with diabetes
performing intense
physical labour
− Treatment with drugs that
may affect cognitive
function
Well-controlled T2DM
treated with one or
more of the following:
− Lifestyle therapy
− Metformin
− Acarbose
− Thiazolidinediones
− Second-generation
SUs
− Incretin-based therapy
− SGLT2 inhibitors
− Basal insulin
Comments These two categories should not fast, however, many of
these patients will choose to do so and this must be
respected. Patients who insist on fasting need to be aware
of the risks associated with fasting, and of techniques to
decrease this risk. They should be provided with an
individualized management plan and be advised on the
measures they can take to minimize these risks. This
includes attending a pre-Ramadan assessment, regular
SMBG, structured education, medication adjustments and
nutritional, exercise advice and Be prepared to stop the fast
in case of frequent hypo-or hyperglycemia or worsening of
other related medical
This category is allowed
to fast and should
receive structured
education, check their
blood glucose
regularly (SMBG) and
adjust medication dose
as per recommendations
Table.1: IDF-DAR stratification of patients with DM during Ramadan fasting

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2- Self-monitoring of blood glucose (SMBG)
Checking blood glucose levels is an essential component of diabetes care,
and patients should be provided with the tools and knowledge to carry out self-
monitoring of blood glucose (SMBG).
Having the skills to self-monitor blood glucose levels can empower patients
with diabetes to effectively self-manage their disease and preventing episodes
of hypo-or hyperglycemia.
Patients should check blood glucose levels whenever they experience
symptoms of hypoglycemia, hyperglycemia or feel unwell, and understand
when they should immediately break the fast.
The frequency of SMBG depends on many factors including the type of
diabetes and current medications:
✓ Once or twice a day for patients at moderate or low risk.
✓ Several times per day for:
−Patients at high or very high risk
−Patients on insulin and/or SU because of the increased risk of
hypoglycemia associated with these medications.
Recommended times to check blood glucose levels during Ramadan fasting
(Fig.2):
1) Pre-dawn meal (suhoor)
2) Morning
3) Midday
4) Mid-afternoon
5) Pre-sunset meal (iftar)
6) 2-hours after iftar
7) At any time when there are symptoms
of hypoglycemia/hyperglycemia or
feeling unwell
Fig.2

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3- Fluids and dietary advice
− Ingestion of large amounts of foods at Iftar meal, should be avoided.
− Ingestion of foods containing “complex” carbohydrates advisable at
suhoor meal, while foods with more simple carbohydrates more
appropriate at Iftar meal.
− Low-glycemic index, high-fiber carbohydrates (e.g. whole grain) are
preferable.
− Divide an adequate amount of calories between suhoor, iftar and if
necessary, 1–2 snacks
− Carbohydrate consumption from vegetables, whole fruits, salad, yoghurt
and dairy products are recommended.
− Ensure meals are well balanced, with 45–50% carbohydrate, 20–30%
protein and < 35% fat (preferably mono and polyunsaturated) (Fig.3).
− Minimizes foods that are high in saturated fats e.g. Ghee, samosa etc
− Iftar should begin with water to rehydrate, and 1–2 dates to raise blood
glucose
− Avoid sugar-heavy desserts, caffeinated and sweetened drinks.
− Hydration should be maintained between meals by drinking water and
non-sweetened beverages.
− Fluid intake should be increased during non-fasting hours.
− Adequate protein and fat should be consumed at suhoor to induce satiety.
− Low calorie snacks such as fruit, nuts, or vegetables may be consumed
between meals
− Take suhoor as late as possible, before the start of the daily fast.
Fig.3: Example of Ramadan plate

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4- Exercise advice during Ramadan
− The exercise program during Ramadan should be modified in its intensity
and timing to avoid hypoglycemic episodes.
− Vigorous exercise is not recommended during fasting because of the
increased risk of hypoglycemia and/or dehydration.
− Patients with diabetes should be encouraged to take regular light-to-
moderate exercise during Ramadan.
− Patients should be reminded that the physical exertions in Tarawih prayers
(e.g. bowing, kneeling and rising) should be considered part of their daily
exercise activities.
5- Medication adjustments during Ramadan fasting
The change in lifestyle and eating patterns during Ramadan makes patients
with diabetes at an increased risk of hypoglycemia during the daytime and
hyperglycemia at night.
The type of diabetes medication can also impact this risk.
Adjustments to the dose and/or timing of some medications or change the
type of medication may be required during Ramadan to minimize the risk of
hypoglycemia in fasting patients.
A) Oral Hypoglycemic Agents (T2D):
1) Metformin:
− Daily dose remains unchanged
− Immediate release:
− OD: Take at iftar;
− BID: Take at iftar and suhoor;
− TID: 1 dose at suhoor, 2 doses at iftar
− Prolonged release: Take at iftar
2) Glitazones (TZDs):
− No dose modifications. Dose can be taken with iftar or suhoor.
3) α-glucosidase inhibitors (e.g. Acarbose)
− No dose modifications. Dose can be taken with iftar or suhoor.

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4) Meglitinides:
− Short-acting Meglitinides can be taken twice daily before Iftar and Suhur
meals.
5) Sulfonylureas (SU):
− Switch to newer SU (gliclazide, glimepiride) where possible: associated
with lower risk of hypoglycemia.
− Glibenclamide should be avoided (high risk of hypoglycemia)
− If OD: take at Iftar, dose may be reduced in patients with good glycemic
control
− If BID: Iftar dose remains unchanged, and half the dose at Suhoor.
6) DPP-4 inhibitors:
− No dose modifications. Dose can be taken with iftar and/or suhoor.
7) GLP-1 RAs:
− Once appropriate dose titration has been achieved before Ramadan (6
weeks before), no further dose modifications are needed.
8) SGLT2 inhibitors:
− No dose modifications
− Dose should be taken with iftar
− Extra clear fluids should be ingested during non-fasting periods
− Should not be used in the elderly, renal impairment, hypotensive
individuals or those taking diuretics.
B) Insulin therapy (T1D or T2D): Switch to insulin analogues where possible.
1) Long- or intermediate-acting basal insulin:
− OD (e.g. NPH*/detemir/glargine/degludec): Take preferably at iftar and
Reduce the dose by 15–30%
− BID (e.g. NPH/determir/glargine): Take usual morning dose at iftar.
Reduce evening dose by 50% and take it at suhoor.
2) Rapid or short-acting (pre-prandial/bolus) insulin:
− Take normal dose at iftar. Omit lunch-time dose. Reduce suhoor dose
by 25–50%

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3) Premixed insulin:
− OD: Take normal dose at iftar.
− BID: Take usual morning dose at iftar. Reduce evening dose by 25–
50% and take at suhoor •
− TID: Omit afternoon dose. Adjust iftar and suhoor doses and carry out
dose titration every 3 days as follow:
Fasting/pre-iftar/pre-suhoor blood glucose Premixed insulin modification
<70 mg/dL or symptoms Reduce by 4 units
70–90 mg/dL Reduce by 2 units
90–126 mg/dL No change required
126–200 mg/dL Increase by 2 units
>200 mg/dL Increase by 4 units
4) Insulin pump:
− Basal rate: Reduce dose by 20–40% in the last 3–4 h of fasting and
increase dose by 0–30% early after iftar
− Bolus rate: Normal carbohydrate counting and insulin sensitivity
principles apply
6- Breaking the fast
Patients should be educated to recognize the symptoms of hypoglycemia and
hyperglycemia (Table. 2), and be advised to test their blood sugar whenever
any of these complications (or an acute illness) occur, and be prepared to
break the fast if necessary.
When to break the fast:
1) Blood glucose < 60 mg/dl at any time of the day.
2) Blood glucose < 70 mg/dl in the first few hours after the start of the fast.
3) Blood glucose > 300 mg/dl.
4) Acute illness, symptoms of hypoglycemia, hyperglycemia or dehydration.
When breaking the fast because of hypoglycemia, patients should consume
a small amount of a fast-acting carbohydrate e.g. a small carton of juice, and
retest their blood sugar after 15-20 minutes.

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Table.2:
Symptoms of hypoglycemia Symptoms of hyperglycemia
− Trembling
− Sweating/chills
− Palpitations
− Hunger
− Altered mental status
− Confusion
− Headache
− Extreme thirst
− Hunger
− Frequent urination
− Fatigue
− Confusion
− Nausea/vomiting
− Abdominal pain
Special populations
Type 1 diabetes
People with T1DM will be advised not to fast because of the risks of severe
complications. However, young adults if stable, healthy, has good hypoglycemic
awareness and complies with their individualized management plan under
medical supervision, then many of these patients can fast safely.
Strategies to ensure safety of individuals with T1DM who choose to fast
include:
✓ Ramadan-focused medical education.
✓ Pre-Ramadan medical assessment including robust assessment of
hypoglycemia awareness.
✓ Following a healthy diet and physical activity pattern,
✓ Modification of insulin regimen.
✓ Frequent SMBG.
✓ When to break the fast.
The elderly
Many older people have enjoyed fasting during Ramadan for many years and
they should not be categorized as high risk based on a specific age but rather
on health status and their social circumstances.
The current risk categorization considers those with old age combined with ill
health as very high risk, however, old age on its own is not considered as an
additional risk factor for fasting.
Anti-diabetic agents, which carry risks for hypoglycemia, should be avoided.

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Pregnant women
Three quarters of Muslim pregnancies overlap with Ramadan and the risk to
both the mother and fetus mean that pregnant women are exempt from
fasting. However, many of these women will choose to fast.
The risk categories proposed by the IDF-DAR take into consideration the
differences between pregnancy in pre-existing diabetes and gestational
diabetes mellitus (GDM). Some important factors to consider include:
− Pregnancy in pre-existing diabetes affects the pregnant woman
throughout the duration of pregnancy, compared to the relatively shorter
duration of GDM which normally develops during the second or third
trimester.
− The type of diabetes medication the woman with diabetes uses pre-
pregnancy: incretins or thiazolidinediones are considered relatively low
risk with regards to safety for fasting. However, during pregnancy, the vast
majority of women with T2DM would be treated with insulin, metformin or
glibenclamide. Insulin and glibenclamide carry a higher risk of
hypoglycemia if fasting.
− Many are concerned about hypoglycemia in Ramadan, however, for
pregnant women hyperglycemia is associated with increased risk for both
mother and baby. For this reason, pregnant women with pre-existing
diabetes or GDM are advised not to fast
Take home message:
− Pre-Ramadan assessment is essential for any patient with diabetes who
intend to observe fast during Ramadan.
− A structured educational program should include information on risk
quantification, blood glucose monitoring, diet, exercise, medication
adjustments, recognition of the symptoms of complications and when to
break the fast to prevent harm.
− Studies have demonstrated a clear benefit of Ramadan-focused
education programs in terms of glycemic control, weight loss and a
reduced risk of hypoglycemic events.
− Modifications in anti-hyperglycemic therapies is needed in diabetic
patients who observe fast during Ramadan.
− Newer anti-hyperglycemic agents (e.g. DPP-4 inhibitors) allow the
patients to observe fast safely with improved glucose control without
risks of hypoglycemia and weight gain.

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Sources:
1. The Quran. 2:183-5.
2. American Diabetes Association. 4. Foundations of care: Education, nutrition, physical activity, smoking
cessation, psychosocial care, and immunization. Diabetes Care 2015;38:S20-30.
3. https://www.daralliance.org/daralliance/wp-content/uploads/2018/01/IDF-DAR-Practical-Guidelines_15-April-
2016_low.pdf
4. Hassanein M et al. Diabetes and Ramadan: Practical guidelines. Diabetes Res Clin Pract (2017), http://dx.doi.
org/10.1016/j.diabres.2017.03.003
5. http://care.diabetesjournals.org/content/27/10/2306.full. Accessed May 16, 2016.
6. http://care.diabetesjournals.org/content/28/9/2305.full.
7. http://drc.bmj.com/content/3/1/e000111.full
8. http://www.joslin.org/info/Ramadan-and-Diabetes.html.
9. https://www.diabetes.org.uk/ramadan
10. BMJ Open Diabetes Res Care 2015; e000108
Prepared by:
Dr/ALSAYED ALSPAGH
Internal medicine, MSc
Consultant of internal medicine, Aim’s clinic, Maldives