Dubai endocrinologist and nutritionist offer a guide on how diabetics can fast during Ramadan

Dubai: Fasting can be therapeutic for diabetics and endocrinologists say it is possible for Type II diabetics to observe the day-long fast during Ramadan under guidance and advise from their doctors.

With widespread incidence of Type II diabetes in the UAE, the condition poses a challenge for Emiratis and expatriates intending to observe the Ramadan fast. According to Diabetes Household Survey of 2017 conducted in Dubai, more than 19.2 per cent of Emiratis have diabetes and approximately 14.6 per cent of the expatriate population is dealing with the condition with a high percentage of undiagnosed diabetics and a wide section of pre-diabetics (with borderline impaired glucose metabolism).

Diabetics can fast under medical guidance

Dr C.P. Patanjali, specialist endocrinologist at Aster Clinics, Dubai, said it was possible for most Type II diabetics to fast, but strictly under medical guidance.

“Not all diabetics can fast. The Type II diabetics can fall into high, moderate and medium health risk categories, depending on their blood sugar control. HbA1C is the indicator for this. HbA1c or glycosylated haemoglobin provides a good idea of an individual’s blood sugar levels for three months. The haemoglobin protein in our red blood cells combines with a molecule of glucose and turns into glycosylated haemoglobin. In non-diabetics, HbA1c is between 5.2, in pre-diabetics the reading is between 5.2-5.6. In those with borderline glucose impairment the reading is between 5.6-6 and in diabetics it can be anything upwards of 6 going up to 14 with 6 being very good control for a diabetic,” explained Dr Patanjali.

Avoid fasting if you are high-risk category diabetic

Ruba Elhourani, the head of nutrition and clinical dietician at RAK Hospital, further elaborated. “High-risk patients are those with an HbA1C above 8 and dependent on insulin and with other complications such as Chronic Kidney Disease or even pregnant women with gestational diabetes. Such people should not fast. Moderate risk patients are those who have an HbA1C up to 8 are obese and take oral pills for sugar,” she said.

“Low-risk diabetics are those with good blood sugar control on oral pills with a HBA1C not more than 7. It is fine for low-to-moderate risk patients to observe the fast under medical guidance.”

Adjusting the medicine or insulin dose prior to fasting

Depending on the kind of medication they are on (injectable or oral pills), a diabetic must adjust his dose as there is a long gap without food and water. Dr Patanjali explained: “Depending upon the kind of insulin the patient is on, he or she will have to check blood sugar before the pre-dawn meal. The dosage will be determined according to the blood sugar levels. Once the meal is consumed and the person has taken fluids, he must check the blood sugar two hours later as well. The blood sugar check must be done throughout the day on the glucose monitor intermittently. Diabetics can have a sudden drop in blood sugar (hypoglycaemia where the individual can experience confusion, sweating, disorientation and even loss of consciousness). If this happens, it is advisable to end the fast, have some dates and water and consult one’s treating doctor immediately. Ideally on doctor’s advice, people tend to reduce the medication or insulin dose and concentrate the medication around the meal time only, after a check of the blood sugar levels,” he explained.

Importance of hydration for diabetics

Elhourani said diabetics fasting during Ramadan must not only be careful to take in enough macro and micronutrients in both their meals, but must also ensure they are well-hydrated. “Type II diabetics can experience severe electrolyte imbalance as not having water for a long period can upset the sodium potassium levels in their body causing weakness and loss of consciousness. Therefore, they must take care to have at least two litres of water during the non-fasting hours. They can choose water-rich fruits and vegetables for suhour and iftar and from the evening when they end their fast, they must make it a point to have a glass of water every hour until they go to bed to maintain proper hydration.”

General nutritional guideline for diabetics

Elhourani advised a low-calorie, nutrition-dense meal for both suhour and iftar that has all the macronutrients (protein, carbohydrates and healthy fats) as well as micronutrients (vitamins, minerals and enzymes) to stay healthy.

“While we advise people to generally choose nutrition over taste, in case of diabetics this is imperative. They have to choose food with a low glycaemic index (release glucose slowly in the blood), whole grains, complex carbs, health oils and fats from nuts and avocado and so on and high quality proteins which are cooked healthily,” explained Elhourani.

She continued, “This means diabetics must avoid oily and fried food at all costs. Diabetics must cut out any fruit juice that can spike their blood sugar.”

Importance of exercise

In order to have a better glucose metabolism, diabetics must undertake a light-to-moderate workout an hour after iftar. This could include a 30-minute walk or a light workout and some stretches that will help them maintain a good muscle tone and aid the blood glucose metabolism, Elhourani added.

The role of sleep

Maintaining a regular sleeping pattern during Ramadan is mandatory for all diabetics and they must have an early night as they have to be up early as well. A disturbance in the sleep pattern releases cortisol or stress hormone, which can result in impaired sugar metabolism, said Dr Patanjali. Therefore, once iftar is over, it is advisable not to stay up for too late or have drinks rich in caffeine that can disturb sleep. People should make sure to hit the bed by 10pm.

Sample menu for Suhour

Portion control is important for diabetics and they need to make sure they are ingesting a protein, complex carbohydrate and healthy fat–balanced meal.

Pre-dawn breakfast

Boiled egg or omelette with cheese and vegetables and a slice of multi-grain bread, a small bowl of porridge made of steel-rolled oats with skimmed, unsweetened milk, a bowl of raw vegetable salad, one medium-sized fruit with low GI such as an apple or pear and a couple of glasses of water.

For ending fast

End fast with two or three dates and clear vegetable, lentil or chicken soup to provide a low-calorie protein replenishment with high water content. It is preferable for diabetics to choose the light brown variety of dates, which are high in fibre and water content. Three dates is equivalent to a serving on one medium fruit while the soup can replenish lost hydration and protein. Elhourani advised that diabetics must have food in phases and slowly reintroduce carbohydrates in their meal during iftar. “There must be no sugar or carbohydrate over load to prevent sudden sugar spikes. Even the hydration should also take place gradually so as to prevent any kind of fluid overload,” she advised.

For iftar

It is best to choose oven-baked or grilled white meat for the main course, accompanied with plenty of vegetables as a side dish and a low GI dense carbohydrate such as couscous, quinoa, barley or rye. “Diabetics are advised to rotate their grain variety each day for a more efficient glucose absorption. They must cut out white rice, processed flour breads and instead of deep-fried items go for the air-fried options. They must skip desserts as they need to avoid high-sugar, high-fat recipes. If too tempted, it is best to exercise portion control and take very small helpings,” explained Elhourani.

Late-night snack

For a pre-bedtime snack, it is advisable to have a handful of soaked nuts and low-GI fruit such as some berries. High sugar items such as rich and oily desserts must be avoided,” she advised.