Fasting with Diabetes by Dr Shahjada Selim

Diabetes Management
During Ramadan
Dr Shahjada Selim
Associate Professor
Department of Endocrinology, BSMMU

Introduction
Fasting during the month of Ramadan is one
of the principal obligatory ritual of the Muslim.
They remain fast from dawn to sunset and
abstain from taking foods, drinks and
medications.
Al-Arouj et al 2010. Diabetes Care. 2010;33(8):1895–1902. doi:10.2337/dc10-0896
The duration of fast varies depending upon the
geography and season, ranging 12.50 hours to
22.00 hours [average 13-18 hours].
4/26/2020 Fasting with DM- Dr Selim 2

94.2% of Muslims with
T2DM fast for at least half
of Ramadan, and two-
thirds fast every day
The Majority of Muslims With T2DM Fast Every Day During Ramadan
(CREED Study)1
Percentage of patients with T2DM fasting for specific periods during
Ramadan1,2
T2DM = type 2 diabetes mellitus.
1. Babineaux SM, et al. Diabet Med. 2015;32(6):819-828.
2.International Diabetes Federation and the DAR International
Alliance. 2016. https://www.idf.org/e-library/guidelines/87-
diabetes-and-ramadan-practical-25. Accessed 8 March 2018.
3.BaHammam A, et al. Appetite. 2010;54(2):426-429. 3. Roky
R, et al. J Sleep Res. 2001;10(4):319-327.
. © 2020 Eli Lilly and Company.
Out of those who
fast at least 15
days, 67.6% fast
every day
67.6%
5.9%
(15 days)
94.2%
(≥15 days)
Typical Sleep and Meal Patterns During
Ramadan and Non-Ramadan Periods1
00:0
0
Non-Ramadan
6:0
0
12:0
0
18:0
0
Ramadan
Asleep
Awake
Physiological changes are most
marked in countries with more
daylight hours1

……Introduction
Onset of Ramadan heralds a sudden shift in meal
times and types, sleep and wakefulness patterns.
Country to country, region to region fasting hours
in daytime vary from short to longer hours of the
24 hours. Again varied climate, weather and
humidity in different regions influence the
metabolic changes in night as well as in day time.

……Introduction
All these variations implicate great changes of
diurnal rhythms, glucose and other metabolic
homeostasis as well as hormonal profiles of the
body.
Sleep pattern are often altered such as decreased
total sleep time, delayed sleep, decreased sleep
period time, decreased REM, non REM sleep
duration. Sleep deprivation and altered pattern will
create great influence on glucose homeostasis.

….Introduction
Changes of food intake and habit will also
produce impact on circadian rhythms such as
body temperature and cortisol level, Leptin,
Adiponectin-all are important to keep glucose
homeostasis even in healthy person.
Most of the changes found in early days of
Ramadan are revealed to revert in pre-Ramadan
state in later days of fasting Ramadan month.

In healthy subjects, fasting causes the release of
glucose by glycogenolysis from liver in early hour
of fasting, followed by in later part of the fasting
hour’s glucose release by gluconeogenesis from
kidney, muscle, and liver to keep normal
glucose homeostasis and maintain energy.
Further prolong fasting fatty acid mobilization
occurs from adipose tissue for fuel and leads to
ketone body formation.
….Introduction

To keep glucose homeostasis in fasting state
beta cells of pancreas release low amount of
insulin and alpha cells release high glucagon.
In addition sympathetic hormones are released
in high amount to maintain the metabolic
changes for glucose homeostasis and to
provide energy in fasting stage.
….Introduction

Other hormones like Leptin, Adiponectin, and
growth hormone are also involved to regulate
appetite, insulin sensitivity and other metabolic
pathways. Exaggeration of these changes are
found more in diabetes with already low insulin
and high glucagon in both fasting and post meal
state resulting high blood glucose level and
mobilization of free fatty acids.
….Introduction

Pathophysiology of Fasting

Pathophysiology of Fasting in Diabetes: Summary
Insulin secretion, which promotes the
storage of glucose in the liver and muscle as
glycogen, is stimulated by feeding in non-
diabetic individuals.
During fasting, circulating glucose levels fall,
leading to decreased secretion of insulin.

Concurrently, levels of glucagon and
catecholamines rise, stimulating the
breakdown of glycogen and
gluconeogenesis.
As fasting becomes prolonged for more
than several hours, glycogen stores
become depleted and there is increased
fatty acid release from adipocytes.
Pathophysiology of Fasting in Diabetes: Summary

As a result, the risks facing in diabetes who intend
to fast are observed.
Risks due to fasting itself should be kept in mind by
the physician and must inform the patient about
unnoticed hypoglycemia, unwanted hyperglycemia,
diabetic ketoacidosis, dehydration and electrolyte
imbalance as well as thromboembolic proneness.
All these risks are also aggravated by
duration of fasting time, food intake pattern,
hot and humid climates.

Key Risks Associated With Ramadan
Fasting in Patients With Diabetes1
1. Al-Arouj M, et al. Diabetes Care. 2005;28(9):2305-2311.
2. Al-Arouj M. J Pak Med Assoc. 2015;65(5 suppl 1): S18-S21.
© 2020 Eli Lilly and Company.
Risks
Hyperglycaemia
Dehydration
and thrombosis
Hypoglycaemia
Diabetic
ketoacidosis

Different studies revealed several folds of high rate
of hypoglycemia as well as hyperglycemia both in
type 1 and type 2. Increased tendency of
hypoglycemia and hyperglycemia are also due to
injudicious meal pattern like fasting in day
time but feasting in night and maladjustment
of anti-diabetic agents.

• Therefore, patients with diabetes should seek
medical advice before deciding to proceed with
Ramadan fasting.
• Most of the uncomplicated type-2 diabetes
patients can safely fast during the holy month of
Ramadan but this needs pre-Ramadan education
and motivation.
• Most of the well controlled or uncomplicated type
2 diabetes patients can with variable ranges of
risks fast but needs:
Management of Diabetes Fasting

• A pre-Ramadan individualized assessment-should be
performed by healthcare professionals around 3 months
prior to the start of fasting.
• The assessment should include:
• Appropriate risk stratification
• Review of positive and adverse experiences from
previous fasting
• Formulate an individualized treatment plan
• Discuss the importance of antihyperglycemic
medication adjustment, meals, physical activity,
frequency of self-monitoring of blood glucose, and
situations where it would be medically indicated to
break the fast.
……Management of Diabetes Fasting

•Diabetic patients who intend to fast
should be categorized into 3 risk
groups
very high risk
high risk
moderate/low risk.
Pre-Ramadan Assessment &
Risk Stratification

IDF-DAR Practical Guidelines Have Created
3 Risk Categories for Patients With Diabetes
Who Fast During Ramadan
DAR = Diabetes and Ramadan International Alliance; IDF = International Diabetes Federation.
International Diabetes Federation and the DAR International Alliance. 2016. https://www.idf.org/e-library/guidelines/87-diabetes-and-ramadan-practical-25.
Accessed 8 March 2018.
Patients who are in the 2 highest categories
of IDF-DAR risk should not fast
Category 1
Very High
Risk
Category 2
High Risk
Category 3
Moderate/
Low Risk

CKD = chronic kidney disease; GDM = gestational
diabetes mellitus; SU = sulphonylurea; T1DM = type
1 diabetes.
International Diabetes Federation and the DAR
International Alliance. 2016. https://www.idf.org/e-
library/guidelines/87-
diabetes-and-ramadan-practical-25. Accessed 8 March
2018.
Patient Characteristics
One or more of the following:
• Severe hypoglycemia within the 3 months prior to
Ramadan
• DKA within the 3 months prior to Ramadan
• Hyperosmolar hyperglycemic state (HHS) within the 3
months prior to Ramadan
• History of recurrent hypoglycemia
• History of hypoglycemia unawareness
• Poorly controlled T2 DM
• T1DM
• Acute illness
• Pregnancy with pre-existing diabetes or GDM treated
with insulin
• Chronic dialysis or CKD stages 4 and 5
• Advanced macrovascular complications
• Old age with ill health
Should not fast
Category 1
Very High
Risk

One or more of the following:
• T2DM with sustained poor glycemic
control*
• Well-controlled T2DM on
multiple dose insulin or mixed
insulin
• CKD stage 3
• Stable macrovascular complications
• Comorbid conditions that present
additional factors
• Intense physical laborer
• Treatment with drugs that may affect
cognitive function
Category
2
High Risk
*Level of glycaemic control to be agreed between
physician and patient, according to multiple factors.
2018.
© 2020 Eli Lilly and Company.
Should not fast

Category 3
Moderate/
Low Risk
Allow to fast*
Well-controlled T2DM treated with one or more of the following:
• Lifestyle therapy
• Metformin
• Acarbose
• Thiazolidinediones
• Second-generation SU
• Incretin-based therapy
• SGLT2i
*Decision to fast based on medical opinion and ability
of the individual to tolerate fast.
SGLT2i = sodium-glucose co-transporter-2 inhibitor.
2018.

Pre-Ramadan Education
 Patients, related family members, friends, HCPs who
manage them, and the general public who support them
should be educated.
 Educational program should be started around 3 months
before Ramadan.
 Ramadan focused structured education program should
include information on
- risk stratification
- diet and exercise
- food intake
- drugs adjustment
- blood glucose monitoring
- recognition of hypoglycemia and other complications and when to
break fast.

Pre-Ramadan Education
 Studies from home and abroad clearly demonstrated
the benefit of Ramadan focused education programs in
terms of
- glycemic control
- weight loss
- reduced risk of hypoglycemic episodes.
 Patient should have a clear understanding of how they
can minimize potential risks by changing their behavior

Modification of Diet & Physical
Activity
• The dietary pattern for fasting Muslims is different
during Ramadan compared with other months of the
year. During Ramadan risk may arise due to
improper eating habits and physical activity.
• Well balanced meal plan and dietary frequency
should be followed as healthy balance diet as done
during pre-Ramadan period.

…..Modification of Diet & Physical Activity
• Small and six frequency healthy balance diet of pre-
Ramadan should be accommodated in three times
of meal frequency between Iftar, dinner and Suhoor
keeping the total daily calorie same.
• Fasting people are advised to avoid exercise
during fasting time. Physical exertion in Tarawih
prayer can be considered as a part of daily exercise
activity.

Modification of Diet &
Physical Activity
Aims of MNT[1] during Ramadan fasting is to-
 Consume same amount of calories, with
balanced proportions of macronutrients, during
the non-fasting period (i.e. sunset to dawn) to
prevent hypoglycemia during the fasting period.
 Distribute the carbohydrate intake equally
among meals to minimize postprandial
hyperglycemia.

….Modification of Diet & Physical Activity
Aims of MNT[1] during Ramadan fasting is to-
 Consider co-morbidities such as hypertension and
dyslipidemia by patients and health care
professionals.
 Avoid weight gain during Ramadan. For obese
patients, weight loss may result in a significant
improvement in glycaemic control and may reduce
cardiovascular risk.

……Modification of Diet & Physical Activity
Dietary advice for patients with diabetes during Ramadan
[2,3]
• Large carbohydrate meals, sugary drinks are to be avoided
• Well balanced meals should be ensured with
- 45–50% carbohydrate
- 20–30% protein
- <35% fat (preferably mono- and polyunsaturated)
• Protein like egg, fish, meat, milk, yoghurt must be included and
carbohydrate like bread, beans, rice, plenty of vegetables and
salads can be added. A moderate amount of healthy dessert is
permitted.

Dietary advice for patients with diabetes during Ramadan [2,3]
• Foods that are high in saturated fats should be
discouraged like ghee, butter, samosas, pakoras,
puri, parata or heavy fried meat. Sugary desserts
like jilapi, laddo, barfi, other sweets must be
avoided. Sweetened drinks are advised to avoid
• Hydration and electrolytes can be maintained
between sunset and sunrise by taking more
drinking water or other non-sweetened beverages
• Suhoor is advised to take close to Fajar Prayer.
Consume an adequate amount of protein and fat at
Suhoor4/26/2020 Fasting with DM- Dr Selim 32

……Modification of Diet & Physical Activity
Common unhealthy nutrition habits (To Avoid)
 Taking particularly large meals at Iftar and taking
deserts loaded with sugar after Iftar, which may result
in severe postprandial hyperglycaemia and weight
gain.
 Taking significant amounts of highly processed
carbohydrates at Iftar, or between Iftar and Suhoor,
which may also cause severe hyperglycaemia.

 Having large and frequent snacks between the two
main meals, which can contribute to longer periods
of hyperglycemia.
 Temptation to take Suhoor early or avoiding Suhoor
meal or less meal, which may result in hypoglycemia
before Iftar, especially when fasting hours are longer
than usual.
 Consumption of large portions of high glycemic
index and high glycemic load carbohydrates at
Suhoor, which can lead to post-prandial
hyperglycemia.4/26/2020 Fasting with DM- Dr Selim 34
Common unhealthy nutrition habits (To Avoid)

 Fasting people are advised to avoid exercise during
fasting time.
 Rigorous exercise is not recommended due to
increased risk of hypoglycemia and dehydration.
 Physical exertion in Tarawih prayer can be
considered as a part of daily exercise activity.
 Rest part of exercise can be done before or after
Tarawih prayer in the house premises.
Exercise Recommendations during
Ramadan Fasting

Modification of Oral anti-
hyperglycemic agents (OADs)
 The choice of oral anti-diabetic drug (OAD) should
be individualized during fasting.
 Generally, the insulin secretagogues have higher
risk of hypoglycemia than the insulin sensitizers.
 There is also need to change the dose and timing
of OAD during Ramadan.
 Second generation Sulfonylurea (Gliclazide,
Glicazide MR, Glimepiride) are preferred
Sulfonylureas.

Modification of OADs
Modification of OAD during Ramadan
Name of drug Modification during Ramadan
Metformin • Daily total dose remains unchanged.
• Once daily dose should be taken at Iftar.
• For twice daily dose, should be taken at Iftar and Suhoor.
• For thrice daily dose, morning dose should be taken at Suhoor
with combined afternoon and evening dose at Iftar.
• Prolonged release preparation should be taken at Iftar.
Sulfonylurea • Switch to newer Sulfonylurea (Gliclazide, Glimepiride) where
possible.
• Glibenclamide should be avoided.
• For once daily dose, the total dose should be taken at Iftar.
Dose may be reduced in patients with good glycemic control.
• For twice daily dose, full pre-Ramadan breakfast dose should
be taken at Iftar and 50% of the dinner dose should be taken in
Suhoor.

Modification of Oral anti-hyperglycemic
agents
Meglitinides Thrice daily dosing may be reduced/
redistributed to two doses taken with iftar and
Suhoor.
Acarbose No dose modification. Pre-Ramadan morning
dose is given at Iftar, lunch dose at dinner (if
taken), and evening dose at Suhoor.

Modification of OADS
Thiazolidinediones • No dose modification. Can be taken at Iftar or
Suhoor.
DPP-4 Inhibitors • No dose modification. Can be taken at Iftar or
Suhoor.
SGLT2 inhibitors • No dose modification.
• Dose should be taken with iftar.
• Extra water should be ingested during non-fasting
periods.
• Should not be used in the elderly, patients with
renal impairment, hypotensive individuals or those
taking diuretics.

Modification of anti-hyperglycemic
injectables
 The main aim for insulin therapy during Ramadan fasting is
to provide adequate insulin to prevent the post-meal
hyperglycemia and to prevent hypoglycemia during the
period of fast.
 Individual risk factors should be identified and patients at
high risk are recommended to avoid fasting while treating
with insulin.
 It is important to switch the pre-Ramadan morning dose of
insulin to Iftar and to reduce the pre-Ramadan evening
dose and switch it to Suhoor.

injectables
 Analog insulin, especially analog basal-bolus
regimen is the safest regimen to be used during
Ramadan fasting.
 GLP-1 RA can be continued in patients with T2DM,
during Ramadan fasting.
 Insulin alone or in combination with OADs and GLP
1RA may also be given.

injectables
Management of Patients with type 1 diabetes:
• Basal-bolus regimen is the preferred protocol of
management as it is thought to be safer, with fewer
episodes of hyper- and hypoglycemia.
• Once- or twice-daily injections of intermediate or long-acting
insulin along with pre meal rapid-acting insulin is the
management of choice

injectables
• Insulin detemir or glargine demonstrate a significant decline in
mean plasma glucose with minimal episodes of mild
hypoglycemia. Similar results are seen with insulin glulisine,
lispro, or aspart used instead of regular insulin in combination
with intermediate-acting insulin injected twice a day.
• Compared with those who do not fast during Ramadan, patients
with type 1 diabetes on insulin pump therapy who fast shows a
slight improvement in HbA1c without increasing the risk of
hypoglycemia

Changes to insulin regimen during Ramadan
A) Basal insulin (NPH, Detemir, Glargine, Degludec)
Once daily –
NPH/detemir/glargine/deglu
dec
Take at Iftar. Reduce dose by 15–30%
BID – NPH/detemir/glargine Take usual morning dose at Iftar.
Reduce evening dose by 50% and take at
Suhoor
A) Rapid/short acting insulin: Bolus [(analogue-Lispro,Glulisine,Aspart)/
regular]
Once, twice or thrice daily Take normal dose at Iftar.
Omit lunch time dose.
Reduce Suhoor dose by 25–50%

Changes to insulin regimen during Ramadan
A)Premix(analogue-30/70, 50/50; conventional 30/70, 50/50,
25/75):
Once daily Take normal dose at Iftar
Twice daily Take usual morning dose at Iftar.
Reduce evening dose by 25–50%
and take at Suhoor
Thrice daily Omit afternoon dose.
Adjust Iftar and Suhoor doses
Dose titration should be performed every three days and dose
adjustments made according to BG levels

Insulin dose titration algorithm during fasting
Fasting/before breaking
fast
Insulin units
<70 mg/dL (3.9 mmol/L) or
symptoms of hypoglycemia
Break the fast and down-
titrate
<90 mg/dL (5.0 mmol/L) −2 IU
90–126 mg/dL (5.0–7.0
mmol/L)
No change
126-200 mg/dL (7.0-11.1
mmol/L)
+2 IU
>200 mg/dl (11.1 mmol/L) +4 IU

Modification of anti-hyperglycemic injectables
Adjustment of GLP-1 analogue
Pre-Ramadan schedule Ramadan schedule
 Single dose before
breakfast
 Exenatide may be used
twice within1hr before meal
 Same dose before Iftar
 Exenatide same as pre-
Ramadan before Iftar/or
Suhoor

Monitoring during Ramadan
 Monitoring during Ramadan fasting is very
important for the prevention of any acute
complications and also for medication
adjustment.
 Every diabetic patient willing for fasting must
have their own glucometer.
 Blood sugar monitoring in Ramadan fasting is
approved by Islamic Scholars and does not
invalidate religious fast.

More Frequent Blood Glucose Monitoring During the Day
Is Recommended1,2
*Consider individualisation of care.
1.International Diabetes Federation and the DAR International Alliance. 2016.
https://www.idf.org/e-library/guidelines/87- diabetes-and-ramadan-practical-25. Accessed 8
March 2018.
2.Hassanein M, et al. Indian J Endocrinol Metab. 2014;18(6):794-799. 3. Lessan N, et al.
Diabetes Metab. 2015;41(1):28-36.
Pre-dawn
meal (suhoor)
Sunset meal
(iftar)
All patients should break
their fast if:
• Blood glucose is <70 mg/dL
(3.9 mmoI/L)
 Re-check within 1 hour if
blood glucose is 70-90
mg/dL (3.9-5.0 mmoI/L)
• Blood glucose is >300
mg/dL*
(16.7 mmoI/L)
• Symptoms of
hypoglycaemia or acute
illness occur
Night
Day
Morning
Midday (12:00)
Pre-dawn Evening
Afternoon
Morning
Midday
Mid-afternoon
2 hours
after iftar
Dawn Sunset
Midnight (00:00)
Or at any time when there are symptoms of hypoglycaemia or hyperglycaemia or if feeling unwell
10.0
8.0
Time (hours)
Glucose
(mmol/L)
6.0
Fasting
Non-fasting
Ifta
r

Monitoring during Ramadan
Date Pre
Suhoor
2 hrs after
Suhoor
Around
10 am
11 am to
2 pm
Pre
Iftar
2 hrs
after
Iftar
Any time
of the day
Ramadan log book

Emergencies related to diabetes
during Ramadan
• Major complications associated with fasting in
patients with diabetes are
- Hypoglycemia
- Hyperglycemia
- diabetic ketoacidosis/HHS
- Dehydration
- thrombosis.
• Inappropriate adjustment of medication, lifestyle
and physical activity are main contributor to
development of hypoglycemia.

…..Emergencies related to diabetes during Ramadan
• Hyperglycemia may result from
- excessive reduction of dosage of medications
- an increase in food and/ or sugar intake.
• Patients with type 1 diabetes are at an increased
risk for development of DKA, particularly if they are
grossly hyperglycemic before Ramadan. Risk for
DKA is further increased due to inappropriate
reduction of insulin dosages.

• Patients with
- moderate to severe hyperglycemia (average
blood glucose 150-300 mg/dl) before fast
- renal insufficiency
- advanced micro-/ macrovascular
complications and other comorbid conditions
are at increased risk to develop DKA or HHS.
….Emergencies related to diabetes during Ramadan

• Dehydration may occur due to
- hot-humid climates
- limited fluid intake during prolonged fast
- excess hard physical activity
- Hyperglycemia
- Increased blood viscosity secondary to
dehydration may enhance the risk of
thrombosis.
….Emergencies related to diabetes during Ramadan

• The key components to minimize acute
complications are
- risk quantification
- empowering people with diabetes with
Ramadan focused education
- blood glucose monitoring
- nutritional and exercise advice
- appropriate drug-dose modification
- addressing comorbidities
- personal circumstances.
…Emergencies related to diabetes during Ramadan

• A post-Ramadan follow-up plan consultation is
recommended
- to review medication and regimen
readjustments
- How the patient handled fasting
- Level of glycemic control
- Incidence of hypo/hyperglycemia
- Any acute complication
• Patients should note BMI, S. creatinine, lipid profile
and HbA1c and observe the changes
Post Ramadan Follow up

 Pre-Ramadan education and motivation is
very important to prevent diabetes related
complications.
Summary:
 Most of the uncomplicated T2DM patients
can fast during Ramadan safely.
 Islam allows diabetic persons to have
regular blood test while fasting.

…Summary:
 Fasting along with regular prayer have
been proved to aid in better control of
diabetes.
 Ramadan focused structured education and
individualized patient centered approach are
the cornerstone of safe fasting.
 Physicians role is vital for the management
of safe fasting in Ramadan.

Fasting with Diabetes by Dr Shahjada Selim

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Fasting with Diabetes by Dr Shahjada Selim