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Ramadan fasting is practiced by Muslims, where they abstain from eating and drinking, between dawn and dusk daily, for a period of 29-30 days. However, fasting during Ramadan is not obligatory for certain groups, such as children (before puberty), elderly, pregnant or breastfeeding women and those who are suffering chronic medical conditions. This includes people with diabetes.
For the people with diabetes, fasting may be challenging due to potentially increased risk of:
Decreased food/sugar intake during daytime may lead to low blood sugar level. Signs of hypoglycemia include:
A fast or pounding heartbeat
Fasting can cause hyperglycemia too! This is due to the excessive reduction of medication dosages to prevent hypoglycemia, and an increase in food and/or sugar intake during non-fasting hours. Signs of hyperglycemia include:
Needing to pee frequently
Recurrent infections (bladder infections, vaginal infections and skin infections)
This happens because of restriction in fluid intake, especially if the fasting is prolonged. Signs of dehydration include:
Feeling dizzy or lightheadedness
A dry mouth, lips and eyes
Women with diabetes should be strongly advised against fasting during Ramadan.
Children and adolescents with good sugar control who do regular self-monitoring can fast safely if they receive close follow-up during the month of Ramadan and both children and their families are well educated about their illness prior to Ramadan.
Most stable patients on hemodialysis and peritoneal dialysis can fast, if they strictly adhere to their medications and dialysis therapy in addition to their dietary restrictions. They also should be followed-up closely to detect any complications early.
Elderly patients with poorly controlled chronic medical conditions such as diabetes and hypertension are exempted from fasting.
The key is to maintain a healthy balanced diet. It is encouraged to consume complex carbohydrates, which take a longer time to digest, in order to provide the energy you need. The examples are whole grains, breads, rice, vegetables, legumes and fruits. Also, distributing calories over 2-3 smaller meals during non-fasting intervals helps stabilize blood sugar. It is also important to:
Never skip Sahur. Sahur should consist of a balanced meal with adequate carbohydrate taken as late as possible just before Imsak to avoid unnecessary prolonged fasting.
Do not delay “berbuka” i.e. the breaking of the fast at sunset, also known as Iftar. Limit intake of high-sugary foods e.g. kuih. However, 1-2 Kurma (dates) at the start of Iftar may be taken as part of carbohydrate exchange. Main meal is encouraged after Maghrib prayers.
Supper after Tarawih can be taken as a replacement for a pre-bed snack.
Include fruits and vegetables at both Sahur and Iftar. High fibre carbohydrates are encouraged at all meals.
Limit fried or fatty foods.
Limit intake of highly salted foods to reduce risk of dehydration.
Sufficient fluid must be taken to replenish fluid loss during the day. Aim for 8 glasses a day. Choose sugar-free drinks. Drink adequately at Sahur.
Exercise and physical activities also need to be adjusted! It is recommended to carry out light and moderate intensity exercise on a regular basis. Avoid vigorous activities during fasting time as it may cause hypoglycemia. The preferred timing of exercise is 1-2 hours after Iftar. In that way, you will be able to fuel and hydrate both before and after exercising to ensure your body is fully energised. Just make sure you have time for your body to wind down ahead of bed time if you plan to slot exercise routine after breaking fast.
It is important to never skip your medications without doctor’s advice. However, your anti-diabetic medications might need some dosage and timing adjustments, this includes your insulins. Remember to always consult a doctor or a pharmacist before you make any adjustments to your medications!
It is important to test your blood sugars, and more often during fasting period and especially if you are not feeling well, known as self-monitoring of blood sugar (SMBG). Finger prick for SMBG does not constitute breaking of fast. For those who are on insulins, timing of SMBG can reflect adequacy of insulin dose. Different types of insulin have different onset time and hence the timing of glucose monitoring may vary too. Talk to a doctor or a pharmacist before conducting SMBG based on your medications.
When fasting adversely affects health, one must always and immediately end his/her fast. These conditions are:
Blood sugar <3.9 mmol/L (Re-check within 1 hour if blood sugar is within 3.0-5.0 mmol/L)
Blood sugar >16.6 mmol/L
Knowing how to manage your diabetes during Ramadan month is extremely important in order to control high blood sugar symptoms, avoid complications and prevent deterioration in blood sugar control. Adjust your meal and exercise accordingly. Take your medications and insulin as advised by healthcare professionals. Perform SMBG at the right timing as instructed. Once your body feels unwell, end the fast. Your health is all that matters. Ramadan Mubarak!
Medically reviewed by Ashwini Nair, MB BCh BAO.
International Diabetes Federation, Diabetes and Ramadan (DAR) International Alliance. Diabetes and Ramadan Practical Guidelines 2021. January 2021.
Ibrahim M, Davies MJ, Ahmad E, et al. Recommendations for management of diabetes during Ramadan: update 2020, applying the principles of the ADA/EASD consensus. BMJ Open Diabetes Res Care. 2020;8(1):e001248. doi:10.1136/bmjdrc-2020-001248
Loke SC. A Prospective Cohort Study on the Effect of Various Risk Factors on Hypoglycaemia in Diabetics Who Fast During Ramadan. 2010;65(1):4.
Ministry of Health Malaysia, Malaysia Endocrine & Metabolic Society, Practical Guide in Diabetes Management in Ramadan 2015. 22 June 2015.
Karamat MA, Syed A, Hanif W. Review of diabetes management and guidelines during Ramadan. J R Soc Med. 2010;103(4):139-147. doi:10.1258/jrsm.2010.090254
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