Diabetes Management and Ramadan: What does ADA say?

Ramadan is a lunar based fasting month for Muslims. Muslims who fast during this time should refrain from eating, drinking, use of oral medications and smoking from predawn to post sunset, with no restrictions on food or fluid intake between sunset and dawn. Muslims with diabetes insist on fasting during the holy month, thus creating challenge for themselves and their health care providers. In this article we enumerated some risk factors associated with diabetic patients and how to manage diabetes in Ramadan, according to the ADA recommendations shared in 2005.

Risk associated with fasting in patients with diabetes.

Hypoglycemia: Reduced food intake is a well-known risk factor for developing hypoglycemia. The effect of fasting during Ramadan on hypoglycemic rates is not well known. But, in a study conducted it was observed that fasting during Ramadan increased the risk of severe hypoglycemia by 4.7 fold in patients with type 1 diabetes and 7.5-fold in patients with type 2 diabetes. In addition, the risk of severe hypoglycemia was more common in patient in whose dosage of oral hypoglycemic agents or insulin was changed as well as those who reported a significant change in their lifestyle.

Hyperglycemia: Glycemic control deteriorated, improved, or showed no change in patients who fasted during Ramadan. A study conducted showed 5 fold increase in the incidence of severe hyperglycemia (required hospitalization) for patients with type 2 diabetes and 3 fold increase in the incidence of severe hyperglycemia with or without ketoacidosis in patients with type 1 diabetes. This can be attributed to excess reduction in medication dose for preventing hypoglycemia. Patients with reported increase in food and/or sugar intake had higher rates of severe hyperglycemia.

Diabetic ketoacidosis: Patients with type 1 diabetes fasting during Ramadan have a greater risk of developing diabetic ketoacidosis, especially if their diabetes is poorly controlled. The risk is increased even further because of excessive reduction of insulin dose as food intake too is relatively reduced during that time.

Dehydration and thrombosis: Fluid intake limitation during the fast if prolonged, leads to dehydration (becomes severe in hot and humid climates and in patients who perform physical labor).

Hyperglycemia causes an osmotic diuresis, adding to the volume and electrolyte depletion. In patients with preexisting autonomic neuropathy orthostatic hypotension may be developed. Syncope, falls, injuries, and bone fractures may occur from hypovolemia and the associated hypotension. Blood viscosity may be increased due to dehydration, which may enhance the risk of thrombosis and stroke.

Managing diabetes in Ramadan

1. Frequent monitoring of glycaemia: especially important for patients with type 1 & 2 diabetes requiring insulin.

2. Nutrition: Have a well-balanced diet. Avoid large amount of food rich in carbohydrates and fats at sunset. Foods having complex carbohydrate ((slow digesting foods) should be had as a predawn meal and must be eaten as late as possible before start of daily fast. Fluid intake must be increased during non-fasting hours.

3. Exercise: Normal physical activity may be maintained. Avoid excessive physical activity, which can lead to higher risk of hypoglycemia, especially during few hours before sunset meal.

4. Breaking the fast: Fast must be broken if

• Feeling hypoglycemic (blood glucose of 60 mg/dl). Blood glucose may drop further if treatment is delayed.
• Blood glucose reaches 70 mg/dl in first few hours after start of sunset and especially if insulin, sulfonylurea drugs, or meglitinide are taken at predawn.
• Blood glucose exceeds 300 mg/dl.
• Avoid fasting on sick days

5. Pre-Ramadan medical assessment: should be undertaken 1–2 months before Ramadan. During this time, appropriate blood studies need to be done and evaluated. Individualized advice must be provided if there is any potential risk to the patient. In addition, necessary changes in diet or medication regimen should be made.

6. Ramadan-focused structured diabetes education: Healthcare professionals need to be trained to deliver structured diabetes education during Ramadan, which should include:

• Glucose monitoring importance during fasting and nonfasting hours.
• When fast should not be done or stopped.
• Planning of meal if feeling hypoglycemic and dehydrated during long fasting hours.
• Timing and intensity of physical activity during fasting.
• Importance of diabetes-related medications and its risk during fasting.

7. Managing of patients with type 1 diabetes

• Close monitoring and frequent insulin adjustments are essential for avoiding hypo- or hyperglycemia in patients with type 1 diabetes.
• Continuous subcutaneous insulin infusion (pump) management can also be done, but is substantially expensive.

8. Managing of patients with type 2 diabetes:
9. Diet-controlled patients : there is a potential risk for occurrence of postprandial hyperglycemia in type 2 diabetic patients. In such cases:

• Spreading calories over 2 to 3 smaller meals during the nonfasting interval may help in preventing excessive postprandial hyperglycemia.
• Intensity and timing of physical activity may be modified e.g.,2 h after the sunset meal.

1. Patients treated with oral agents: choice of oral agents should be individualized.
2. Patients on metformin : have limited possibility of severe hypoglycemia and may fast safely. However, dose timing should be modified so as to provide 2/3rd total daily dose with the sunset meal and the 1/3rd before the predawn meal.
3. Use of sulfonylurea’s: is unsuitable for use during Ramadan as it posses inherent risk of hypoglycemia. Use of these drugs should be done with individualized with caution. Chlorpropamide use is contraindicated during Ramadan due to risk of prolonged and unpredictable hypoglycemia.
4. Short-acting insulin secretagogues: could be taken two times daily before the sunset and predawn meals.
5. Incretin-based therapy: drugs such as Exenatide in particular, can be given before meals to minimize appetite and promote weight loss. Due to its short half-life of 2 hrs, it’s not associated a substantial effect on fasting glucose.
6. Patients treated with insulin: To maintain necessary levels of basal insulin and preventing fasting hyperglycemia, use of intermediate- or long acting insulin preparations and short acting insulin need to be given before meals. Also, injecting long-acting or intermediate-acting insulin can give adequate coverage in few patients as long as dosage is appropriately individualized.
7. Insulin Pumps: Frequent glucose monitoring is needed due to failure of the pump infusion site can result in severe deterioration in control over a few hours. Patients with type 1 diabetes must be fully educated and facile about the use of an insulin pump. Before Ramadan, they should receive adequate training and education with respect to self management and insulin dose adjustment. Also, how to adjust their infusion rates as per results of frequent home blood glucose monitoring must be taught.

9. Pregnancy and fasting during Ramadan: Women with presentational or gestational diabetes are at increasingly high risk and should be strongly advised not to fast during Ramadan. However, if they insist to fast, then special attention must be given to their care. Pre-Ramadan evaluation of their medical condition should be carried out that includes, preconception care with emphasis on achieving near-normal blood glucose and A1C values, counseling regarding maternal and fetal complications associated with poor glycemic control, self management education skills. These patients should be managed in high-risk clinics having obstetrician, diabelogists, a nutritionist, and diabetes nurse educators. Appropriate diet and intensive insulin therapy should be given to pregnant patients. In addition, frequent monitoring and insulin dose adjustment is necessary.

10. Management of hypertension and dyslipidemia: Dehydration, volume depletion, and tendency towards hypotension may occur with fasting during Ramadan, especially if fasting is extended for long and is also linked with increased perspiration. Therefore, dose and/or type of anti-hypertensive medications should be adjusted for preventing hypotension. Further, proper counseling need to be given and agents previously given for managing elevated cholesterol and triglycerides should be continued.

Key messages

Fasting by diabetic patients should be done after prolonged discussion with their health care provider so as to discuss the risks involved. Patients, who insist on fasting in Ramadan, must undergo pre-Ramadan assessment and receive appropriate education and instructions related to physical activity, meal planning, glucose monitoring, and dosage and timing of medications. Newer pharmacological agents have lesser hypoglycemic potential and can be specifically useful during Ramadan. Similarly, insulin pump therapy can give greater safety in Ramadan setting.

Read more at

Al-Arouj M,Assaad-Khalil S, Buse J, Fahdil I, Fahmy M, Hafez S, et.al, Recommendations for Management of Diabetes During Ramadan. Diabetes Care; 2010.33 (8), 1895-1902.