Managing your Diabetes during Ramadan A Guide for Patients Introduction The holy month of Ramadan is a period of prayer, routine work, and charitable activities, with strict fasting where no food or drink can be taken from dawn to sunset. This is a great challenge for people with diabetes, and requires maximum self-discipline. Therefore, as Ramadan approaches, people who have diabetes should consider very carefully whether fasting is advisable for them. This Guide aims to remind you of the important points about diabetes explain how fasting during Ramadan might affect your diabetes advise you what questions you should ask yourself or your doctor before deciding to fast during Ramadan provide some hints about how to avoid problems during fasting What is diabetes? Diabetes is a condition where the level of glucose (sugar) in the blood is higher than it should be. In people who are not diabetic, their blood glucose levels are controlled by the production of a hormone called insulin from an organ in the body called the pancreas. In someone with diabetes, either insulin is not produced at all, or the body cannot make enough of it, or the body cannot use what it produces efficiently. As a result, glucose levels in the blood build up, and eventually the body gets rid of it in the urine. When treatment is effective, glucose is no longer found in the urine. Two main types of diabetes occur: Type 1 diabetes develops in younger people, normally under the age of 30. It results from the failure of the pancreas to produce enough insulin. Type 1 diabetics need to take injections of insulin to control their blood glucose levels. Type 2 diabetes develops usually in people over the age of 30 and the risk of developing the disease increases with age and is often linked to obesity. Some Type 2 diabetics can keep their blood glucose levels under control just by following a recommended diet, others will need tablets as well, and some will need insulin. Although many Type 2 diabetics do not need insulin for some years after diagnosis, if at all, the risk of complications is the same as for Type 1. Over time, constantly high blood glucose levels often lead to complications such as: infections those are slow to heal blindness kidney failure stroke heart disease
foot and leg disorders Sometimes it is the symptoms of these complications, rather than the diabetes itself, that lead to a diagnosis of Type 2 diabetes. The risk of complications is the reason why it is so important to keep your blood glucose levels within the range recommended by your doctor. You will have been advised by your doctor what routine checks you should be doing, and if you have any concerns and need further advice you should not hesitate to ask for it. How might fasting during Ramadan affect my diabetes? This will vary; depending on the type of treatment you are receiving for your diabetes, and whether you have any other health problems. A very important part of managing your diabetes well is keeping your blood glucose at the level recommended by your doctor. Your diet, the amount of exercise you take, and any medications prescribed by your doctor all play their part in this. During Ramadan, however, your normal routine changes. You may be fasting for as much as 18 hours. Not only that, but during the nonfasting hours people often drink large amounts of canned juices and carbonated drinks, and eat a great deal of fried and high carbohydrate food. The result is that blood glucose levels may become very high between Iftar and Sehri, and then drop much too far during the fast. If you experienced very low blood sugar - a hypo - during the fasting hours, it would be necessary for you to break your fast immediately. On the other hand, if your blood glucose level rose too much, and stayed high, there is an increased risk of developing the complications mentioned above. In a very severe case, you could go into a coma and require hospital treatment. Should I fast? Under Islamic law people who are sick, pregnant, or breast-feeding (if their health does not allow), and the very weak, old, or very young, are not required to fast during Ramadan. In general, people with diabetes are not expected to fast, but many wish to do so. In that case, it is very important to prepare yourself for fasting as best you can, and to ask your doctor for advice if you are in doubt about how safe fasting would be for you. What kind of treatment are you receiving for your diabetes? It can be difficult to fast safely if your diabetes is being treated with insulin, because of the risk of a hypo. Although the type of insulin, and the doses and timing of your injections, can be altered to reduce the risk, this needs to be done only on the advice of your doctor. People taking Metformin should be able to fast safely, by taking the usual morning dose at Iftar and the usual evening dose at Sehri. If you normally also take a dose at mid-day, this should be taken at Iftar. Some people may feel unwell, however, in which case your doctor can advise on whether you should reduce the dose or stop taking Metformin during Ramadan. If you are taking one or more of the other drugs (e.g. chlorpropramide, glicazide or glibenclamide) used to control blood glucose levels you should consult your doctor before fasting begins. On the other hand, if your diabetes is treated by diet and exercise, you should be able to manage very well. Fasting may even be good for you, especially if you are very overweight! How easy has it been for you to keep your blood glucose at the level recommended by your doctor? If it has been difficult to keep your blood glucose levels steady, and/or if you have had your treatment changed a lot recently, it is probably safer not to fast. Certainly, you should discuss with your doctor
whether fasting is advisable for you this year, and if you do decide to fast you should follow their advice particularly carefully. Do you have any of the complications of diabetes? In general, if you have any of the complications of diabetes (e.g. heart disease or kidney problems) fasting is not recommended. If you feel strongly that you want to fast, it is very important to discuss this with your doctor first. Have you fasted before? Did you have any problems? What were they? How easy were they to put right? Your past experience of fasting in Ramadan will be quite a good guide to assessing how you will manage this time. However, if there have been significant changes in your treatment since the last time you fasted, or if you have been diagnosed with a complication of diabetes, you should consult your doctor before fasting again. Protecting your health during Ramadan People with diabetes who decide to fast during Ramadan need to make sure they do not skip meals take any medication as prescribed avoid over-eating at Sehri or Iftar, as this leads to weight gain and high blood sugar levels remain as physically active as is normal for them, unless advised otherwise The benefits of fasting in Ramadan appear only in those patients who maintain their diet, avoiding the high calorie and highly processed foods prepared during this time. As fasting may last for as much as 18 hours, the best things to eat are those which release their energy slowly and are rich in fibre. These foods can last for up to 8 hours, while foods which release their energy quickly last for only 3 or 4 hours. Slow energy release foods include grains and seeds like barley, wheat, oats, millet, semolina, beans, lentils, wholemeal flour, unpolished rice, etc. These are also called complex carbohydrates. Quick energy release foods generally contain large amounts of sugar or white flour (also known as refined carbohydrates). Fibre-rich foods include whole wheat, foods containing bran, grains, seeds, vegetables (e.g. green beans, peas, marrow, and spinach), fruit with skin, dried fruit (especially dried apricots, figs, and prunes), almonds, etc. It is sensible to: if at all possible, have your meal at Sehri at the proper hour before sunrise, not at midnight, as this will spread out your energy intake more evenly and result in more balanced blood glucose levels during fasting drink as much water or sugar-free drinks as possible between Iftar and bedtime, and use a sweetener rather than sugar if you need to fill up on starchy foods such as basmati rice, chapati, or granary bread include fruits, vegetables, dhal, and yoghurt in your meals at Iftar and at Sehri limit the amount of sweet foods taken at Iftar (i.e. after sunset) limit your intake of fried and fatty foods (e.g. paratha, puri, samosas, chevera, pakoras, katlamas, fried kebabs, naan or bombay mix) as much as possible Common complaints during Ramadan include
constipation (too little fibre and water in the diet) indigestion (from over-eating, especially of fried, fatty or spicy foods) muscle cramps (not enough vegetables, fruit, meat, or dairy products in the diet) headaches (due to caffeine and tobacco withdrawal) These minor problems can be easily dealt with by treating the cause. Preparing for Ramadan by reducing your caffeine intake gradually in the week or so beforehand will help. Smoking is not allowed during Ramadan, so if you are a smoker, use Ramadan as an opportunity to give it up nothing will benefit your general health more! As a person with diabetes the additional problems you may experience are a hypo attack dehydration (where the body does not have enough fluid) high blood glucose levels, leading to ketoacidosis ( diabetic coma ) if not treated Symptoms of a hypo The pattern of symptoms varies from person to person, and experienced diabetics (and their families and friends) learn to recognise what is typical for them. Common symptoms include: weakness of the legs double or blurred vision confusion lack of concentration headache nausea sweating rapid heart beat feelings of panic or anxiety trembling bad temper tingling of the lips and tongue looking pale sleepiness hunger change in behaviour when severe: convulsions and loss of consciousness What to do if you have symptoms of a hypo STOP what you are doing, especially if you are driving or using moving machinery TAKE two lumps of sugar OR three glucose tablets OR two teaspoonfuls of sugar in squash OR a glass of water with a couple of biscuits REPEAT this if the symptoms do not go away within a few minutes If still not better, call for medical help If better, TAKE two slices of bread and a cup of milk, or a proper meal, to avoid further hypos
Remember to keep glucose tablets, sugar, or a sugary drink with you at all times in case of emergency. Do not hesitate to break your fast if you (or others around you) have good reason to believe you are going hypo. High blood glucose levels Unlike during a hypo, when someone s blood glucose is rising out of control, the symptoms develop over some time, and include: thirst nausea rapid breathing drowsiness frequently passing urine stomach pain flushed, dry skin loss of consciousness In the early stages, if the symptoms are less severe, advice over the phone from the doctor may be enough to deal with the problem. It will be important to check blood glucose levels as advised by the doctor and also to check the urine for ketones. Ketones are produced when the body uses fat to create energy, instead of glucose. This happens when glucose is not being removed from the blood stream by insulin, and is therefore not available for energy production. If you are vomiting and unable to keep fluids down (you need to be drinking at least 4 pints or 2.5 litres a day) you should go to hospital for urgent treatment.