Diabetes and fasting – guide from ICLDC

As its the first day of Ramadan, I have some amazing information from Imperial College London Diabetes Centre (ICLDC), the one-stop, state-of-the-art, out-patient facility that specialises in diabetes treatment, research, training and public health awareness. It is in question and answer form so you can relate to it better.

Diabetes and Fasting

Is it Ok for me to fast during the Holy Month of Ramadan, if I am living with diabetes?

During fasting, about eight hours after the last meal our bodies start to make use of energy stores to keep blood glucose (sugar) levels normal. For most people, this is not harmful.

However, a problem can occur if you are living with diabetes, such as the risk of high glucose levels following the larger meals that we eat before and after fasting at Suhoor and Iftar.

Of course, this year the fasting period is long (15 hours in the UAE) meaning that the risk of Hypoglycaemia (high blood sugar levels) and dehydration (lack of water) are high.

It is very important that anyone living with type 1 diabetes understand that they are at a higher risk compared to those with type 2 diabetes when fasting during the Holy Month of Ramadan.

It is crucial that if you are a type 1 diabetes patient and intend to fast, that you are closely supervised and ensure that your blood sugar is regularly monitored to mitigate health risks.

If you are living with type 2 diabetes, generally it is perfectly safe to fast during Ramadan provided that you talk to your doctor about your plans and prepare yourself well. 

But, it is not safe for everyone living with type 2.

Your ability to fast safely often depends on your prescribed medication, and therefore it is really important for you and your doctor to assess your medication programme before the start of Ramadan and/or your fast. Your doctor will guide you to create a fasting plan which works for you.

A lot depends on how well your diabetes is controlled, especially if you’re prone to either frequent high blood sugar levels (Hyperglycemia), or low blood sugar levels (Hypoglycemia).

For example, if you are taking certain tablets and/or insulin, fasting carries the risk of Hypoglycaemia, or high blood glucose levels during a fast are a possible risk, and in extreme cases, can lead to Diabetic Ketoacidosis (DKA), a serious condition requiring hospital treatment.

What happens to my body during fasting?

During fasting, at about eight hours after the last meal our bodies start to use energy stores to keep our blood glucose (sugar) levels normal. For most people, this is not harmful. However for someone living with diabetes, especially if you take certain tablets or insulin, you are at risk of Hypoglycaemia (low blood glucose levels), Hypoglycaemia, (high glucose levels) and dehydration (lack of water).

If I am living with type 1 diabetes, is fasting risky?

In general, people living with type 1 diabe­tes are at very high risk of develop­ing severe complications, and are strongly advised to not fast during Ramadan.

If you are living with type 1 diabetes and really do want to fast, you must consult with your doctor before embarking on the daily fast.

What are the risks if I fast and I am living with type 2 diabetes?

If you are living with type 2 diabetes and have successfully embraced a healthy lifestyle by maintaining a normal body weight through a practice of a balanced diet and regular physical activity, the risks associated with fasting are quite low.

However, following a period of fasting if a very large, excessive meal is consumed there is a potential risk of post-meal Hyperglycaemia after the pre-dawn and sunset meals.

One simple solution is to distribute energy intake over two to three smaller meals during the non-fasting interval. This may help you avoid post-meal Hy­perglycaemia. 

As with diet, your daily exercise should be less intense to avoid episodes of Hypoglycaemia.

If you are taking prescribed oral medications and insulin, do consult your doctor to discuss the risks, which will vary from person to person.

If I am living with diabetes, do I need to go on a special diet during Ramadan?

The good news is if you are already following a balanced diet, as is recommended for everyone, living with type 2 diabetes or not, then there is a big chance that you do not have to change the ingredients of your diet. In fact you should eat as you normally do, with the only difference being the time you eat your meals, rather than quantity or type of food consumed.

The Ramadan diet should be kept simple and contain foods from all the food groups including:

Bread, cereals or rice

Meat, chicken, fish or beans

Milk, laban or yogurt

Fruits and vegetables

Iftar is the meal that breaks the fast, just after sunset, after the long hours of fasting. It is important however that it remains a meal and does not become a feast!

One other thing to be particularly aware of is the risk of increasing blood sugar levels after Iftar, especially if you eat sweet food.

Also, you must take special care to drink plenty of water during the non-fasting hours, so that you remain comfortably hydrated during fasting hours.

At Suhoor you should eat starchy carbohydrates which release energy slowly, such as multigrain bread, oat-based cereals, basmati rice together with beans, pulses, lentils fruit and vegetables.

Other foods which will keep your blood glucose levels more stable throughout the fast include pitta bread, chapattis and semolina. As with all meals, eat sensibly, do not over eat and remember to drink plenty of water.

What are the risks of fasting while living with diabetes during pregnancy?

Pregnant women are strongly advised not to fast, and indeed Islam releases a pregnant woman from fasting during Ramadan. However, some still like to fast and if diabetes (including gestational diabetes) is also present, this is considered a high-risk scenario that requires intensive care.

Pregnancy involves a state of increased insensitivity to insulin and insulin secretion.

During fasting, blood glucose levels are generally lower but post-meal glucose and insulin levels remain substantially higher in healthy pregnant women than in women who are not pregnant.

Elevated blood glucose levels during pregnancy may be associated with increased risk for major congenital abnormalities.

It should also be remembered that the issues concerning the management of type 1 diabetes and type 2 diabetes also apply to pregnant women, along with more frequent monitoring and insulin dose adjustment.

Is it Ok for children to fast, and what are the guidelines?

In Islamic teaching, children are not required to fast for Ramadan until they reach the age of puberty. However, in many families, younger children enjoy participating and are encouraged to practice their fasting.

It’s important to make children aware of what fasting involves and to then to practice fasting for a few hours at a time, although fasting for children under the age of seven or eight isn’t advisable.

Children living with diabetes who choose to fast during Ramadan do pose a management challenge for paediatricians as the majority of guidelines and data on safety and metabolic impact of fasting are based on practice and studies on the adult population.

It is very important that fasting only takes place under the watchful eye of the child’s doctor.

 Is there an increased risk of dehydration in hot countries, like the UAE?

Yes. Dehydration due to reduced intake of fluids may become severe in hot and humid climates like the UAE, especially among those who perform hard physical labour.

On top of this, Hyperglycaemia can result in the loss of body fluid through excessive urination, and contribute to depletion of electrolytes in the body.

People with pre-existing nerve damage may develop symptoms of low blood pressure like dizziness or light-headedness. This can lead to loss of consciousness and falls sometimes leading to injuries, such as bone fractures.

It is very important that fluid intake during non-fasting hours from Iftar through to Suhoor is maintained at a regular pace.

In the UAE it is very hot during Ramadan. What can people do if they wish to exercise during the Holy Month?

It is good to take some moderate exercise just before you break your fast at Iftar, and again just before going to bed, as well as right before Suhoor.

It will be quite warm during Ramadan this year and outdoor exercise might not always be the best option, so try climbing the stairs. Start slowly and gradually with two flights at a time and refrain from pushing yourself too hard during the first few days.

Of course, after the sun sets and just before dawn breaks a short but brisk walk for at least 10 minutes is a good practise to adopt during Ramadan.

If you decide to pop out to a mall in the evening, park farther away from the entrance, walk the extra distance, and also enjoy a brisk walk around the mall walkways before your embark on your seasonal shopping!

Is it ok to test my blood glucose in Ramadan while I am fasting?

Yes, testing your blood glucose levels regularly is important and will keep you safe while fasting. This will not break your fast.

Do I need to wake up for Suhoor?

Long hours without eating increases the risk of Hypoglycaemia.

You must try to eat a meal at Suhoorjust before sunrise and not at midnight as is common practice. This will help to keep your glucose levels more balanced throughout the fast.

Should I stop taking insulin?

No. You should never stop your insulin. But you must speak to your doctor because you may need to change the dose and times of your insulin injections.

If I smoke is Ramadan a good opportunity to give up?

If you have diabetes smoking increases your risk of heart disease. Since you are not allowed to smoke during fasting hours it is a good chance to build up your self-control and stop smoking. Take advice from your doctor.

Ramadan Fasting Tips From ICLDC

Here are some guidelines to help you enjoy fasting during the Holy Month of Ramadan, and at other times that you choose to fast.

Talk To Your Physician

  • It is possible to manage diabetes and fast, but please do make sure you meet with your doctor for a thorough assessment before to start your fast, especially if you are prescribed medication.
  • Your doctor will guide you how to adjust your doses and help create a plan that works for you in complement to Ramadan fasting hours.

Space Out Your Meals

  • It is a good idea to pace your meals just like a normal diet. During Ramadan, try not to be tempted to eat continuously from Iftar to just before Fajr. At Iftar, try breaking your fast with a light snack such as dates and soup. Then, have a full meal about an hour later, followed by Suhoor, a breakfast meal just before Fajr.

Re-Hydrate Well

  • It is important that you do not get dehydrated. Adequate amount of fluids is recommended and so is the fact that drinks with high sugar are not good. A sudden surge of sugar drinks in your system can result in a state of high blood glucose levels that may require hospital treatment.

Don’t Skip Meals – Have Iftar and Suhoor

  • Remember to eat a balanced meal just before Fajr. If you are on medication, this will help will reduce blood glucose levels.

Consume Good Carbohydrates; Consider Your Options

  • Slow release carbohydrates, known as low-glycaemic, are an excellent option for fasting food. These include wholegrain bread and basmati rice.
  • Fast release carbs, sugary food and food otherwise known as high-glycaemic index are best avoided. High glycaemic starchy food include potatoes and white bread.

Moderate Activity Is Good

  • Moderate physical activity every day is a healthy option. Walking is one of the best recommended activities for moderate exercise. However excessive exercise is best avoided for people who are fasting.

Hope this helps you or your friends/family with diabetes during the fasting month.

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