Abu Dhabi: The holy month of Ramadan is most closely associated with the day-long fast from food and drink. For diabetic patients, however, the decision is not as straightforward.
One in five adults in the UAE is known to be diabetic. The individuals must only fast in Ramadan under close supervision from a doctor, and only while closely monitoring blood sugar levels.
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Islam clearly exempts from fasting any individuals who may end up unwell as a result of abstaining from food and water for a prolonged period.
Patients must also remember that they are allowed in Islam to end their fast if they feel unwell at any time
“During fasting, there is a change in meal timings, meal frequency, hydration status, and sleep patterns. Because of these external changes, there are alterations in blood levels of various hormones like cortisol, growth hormones and leptin, which can lead to various metabolic consequences,” Dr Velmurugan Mannar, Specialist Endocrinology at Aster Clinic, Silicon Oasis and Aster Clinic, Karama, told Gulf News.
Risks for diabetics
Diabetes is broadly classified into Type 1 or Type 2 diabetes, and in both cases, patients who are fasting are at risk of developing hypoglycaemic or low blood sugar, hyperglycaemia or high blood sugar, or dehydration. Each of these conditions further increases the risk of other complications.
“All people with diabetes who are planning to fast during Ramadan should have a pre-Ramadan assessment with their healthcare provider, which is ideally six to eight weeks before the start of Ramadan. Doctors are then able to obtain detailed medical histories and review patient’s glycaemic control and capability to self-manage their diabetes,” said Rola Al Talafha, Diabetic Educator and Nutritionist at Bareen International Hospital.
The exact management of diabetes in Ramadan, and the eventual ability of a patient to successfully fast, depends, to a very large extent, on the type of diabetes a patient has.
Type 2 diabetes mellitus (DM)
Type 2 diabetes is the more common type and, as a lifestyle condition, occurs predominantly in older individuals. It occurs when the body doesn’t make enough insulin, the hormone responsible for regulating blood glucose (by turning sugar into body fat), or if the body’s cells don’t respond normally to the insulin, known as insulin resistance.
While patients with Type 2 diabetes do need to monitor their blood sugar more closely in Ramadan, a vast majority are able to successfully fast, especially if their diabetes is controlled beforehand.
“Up to 95 per cent of my Type 2 diabetic patients are able to safely fast without any difficulties,” Dr Mannar said.
Type 1 DM
Type 1 diabetes is an autoimmune condition that attacks and destroys insulin-producing cells in the pancreas. It is typically diagnosed in childhood, and patients have to be on top of their blood glucose levels.
As a result, it is much riskier for patients with Type 1 diabetes to fast through the day.
“Only 10 per cent of Type 1 diabetics are able to fast safely because of the complex metabolic needs in such patients,” Dr Mannar said.
“This risk of becoming hypoglycaemic is higher than usual when patients go several hours without consuming carbs, and gets even higher if they do any physical activity, even short, low-intensity activity. And when they skip mealtimes, there is a greater risk of developing ketoacidosis, [a potentially life-threatening complication in which the bloodstream is flooded with ketones],” Al Talafha said.
How to fast safely
Type 2 diabetics
- Design an individualised meal plan well before Ramadan. The plan should help maintain an adequate caloric intake, and help avoid excessive weight changes.
- Monitor glucose closely, and make any adjustments to diet and routine to achieve good glucose control and avoid excursion.
- Eat suhour as close to dawn as possible. Do not skip it.
- Be careful with your insulin dose before starting the fast in order to minimise the risk of hypoglycaemia. End your fast if you become hypoglycaemic.
- Distribute your fluid intake throughout the non-fasting hours instead of consuming a large amount just before dawn. This will help maintain adequate hydration.
Type 1 diabetics
- Work with your doctor to adjust your doses or your type of insulin, if necessary.
- Check your blood sugar more frequently.
- To minimise the risk of hypoglycaemia, review your basal insulin doses with your healthcare team before starting your fast.
- End your fast if you become hypoglycaemic or hyperglycaemic, and work to manage your blood sugar.
- Avoid high-intensity physical activity during Ramadan.
Symptoms to watch out for:
• Feelings of general weakness, shivering, sweating, increased heart rate, dizziness, headache, vomiting, breathing difficulties.
• Vomiting and breathing difficulties can in fact indicate ketoacidosis, which requires urgent attention.
What to eat
At suhour
- High-fibre starchy foods like high fibre cereals or oats, buckwheat, bulgur wheat, or brown or wild rice
- Lentils, chickpeas and beans, which are a good source of protein
- Fruits and vegetables
- Water and unsweetened fluids
At iftar
- A limited number of dates. Although most people end their fast with dates, diabetics are better off drinking water to break their fast, or having a single date.
- Sugar-free drinks like water or laban. Fizzy drinks and fruit juices lead to unhealthy blood sugar spikes and increase thirst.
- Non-strachy salads, vegetables
- Fresh fruit
What to limit or avoid
- Sweet treats: It can be tempting to snack on these, especially if family or friends are sharing. But a small amount can make quite an impact on pushing up blood sugar after a day of fasting.
- Caffeine: Minimise consumption of caffeine to avoid dehydration, especially at suhour.
- Fried, oily foods: Try to only have fried and oily food in moderation as too much can lead to unintentional weight gain through Ramadan. These foods can also affect heart health as they tend to be higher in certain saturated fats and salt, which increase your blood cholesterol and blood pressure above healthy levels.
- Salty foods: Avoid salty food such as pickles, olives and salty cheeses at suhour as they can increase thirst during fasting. These foods can also contribute to hypertension when eaten in excess.
Sleep, hydration
In all cases, diabetics have to also be vigilant about their sleep, hydration, and levels of physical activity during the holy month.
“Fasting during Ramadan can cause dehydration because of lack of fluid intake, as well as the hot and humid weather. Dehydration can then result in a higher blood stickiness or viscosity, which increases the chances of blood clots. For those who have diabetes who choose to fast during Ramadan, it is important to drink plenty of water during non-fasting hours,” Al Talafha said.
On the other hand, the need to wake for a pre-dawn meal in Ramadan, as well as the nightly prayers, ends up reducing the total sleep time, or causes sleep delays.
“Sleep deprivation has been associated with decreased glucose tolerance, Short sleep duration is also independently associated with weight gain,” Al Talfha said.
Dr Mannar therefore advised that patients check blood sugars at bedtime, avoid scree time one to two hours before bed, and get some physical activity in the evening if they have Type 2 diabetes.
Exercise
Diabetics must also continue to be active during the holy month. Before iftar, Al Talafha encouraged light physical activity like walking, Patients can also choose to delay vigorous exercise till two hours after iftar.
“When exercising while fasting, be careful if you are on medication as it may increase your risk of hypoglycaemia. It is important that you test your blood sugar levels before and after exercise,” she said.
