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Dubai: Can people with diabetes fast during Ramadan? This is a question often raised by the pious and determined diabetics and the answer to this is affirmative.

Diabetes Mellitus ((DM) is a metabolic disorder owing to the under-performance or the inability of the beta cells in the pancreas to produce the sugar metabolism-regulating hormone insulin. Since fasting would mean abstaining from water or food for long periods, fasting for diabetics who are either insulin or pill dependent can be tricky.

Statistics from a study conducted by the International Diabetes Federation entitled ‘Epidemiology of Diabetes and Ramadan’ (Epidar) carried out in the GCC countries in 2001 indicated that nearly 42.8 per cent of people with Type 1 diabetes and 78.7 per cent people with Type 2 diabetes were able to fast for 15 days during Ramadan. Type I diabetes is caused by the inability of the body to produce the hormone insulin which has to be given externally. Type 2 diabetes which is a late onset of the disease is triggered by a bad lifestyle, lack of exercise and improper nutrition, according to endocrinologists.

In another Epidar study conducted in 2010 in the UAE, it was found that nearly 94.2 per cent people with Type 2 diabetes were able to fast for 15 days and 63.6 per cent were able to fast for all 30 days during the holy month.

With the right kind of medical guidance and counselling, it is not impossible for diabetics to observe the fast. Dr Zain Gulzar, consultant endocrinologist and medical director of the RAK Diabetes Centre in Dubai, told Gulf News: “A lot depends on the type of diabetes and the medications taken by the patient and how controlled is his blood glucose. For example, If one has Type 1 diabetes, is on insulin and the diabetes is poorly controlled, then fasting may be dangerous for that person. If one has Type 2 diabetes which is well-controlled and the type of medications one is taking would not result in low blood sugars or hypoglycaemia, then it is relatively safe to fast in Ramadan.

“Other individuals may require alteration in the medications if planning to fast. It is important for diabetics intending to fast to seek counselling from their endocrinologist as advice on this issue varies from person to person.”

Dr Hamed Farouqi, consultant endocrinologist and director of the Dubai Diabetes Centre, said: “Diabetics intending to fast need to prepare their body weeks before they plan to fast. They need to get their blood sugar and other parameters measured beforehand to gauge how well they would be able to withhold food and water for nearly 16 hours during this particular Ramadan which will begin early and end late as sun will set much later. The basic test that needs to be performed is the glycosylated haemoglobin (HbA1c) reading which is an indicator of how an individual’s sugar metabolism has been for the last three months. Those with a reading of 6.5 to 7 are cleared for fasting. People with 7 or above are discouraged as their blood glucose absorption is impaired and abstaining from food or water for long or altering the medicine or insulin dosage would be detrimental to their health.”

Diet and nutrition

In general, all diabetics have to see how they respond to long hours of abstaining from food or water. Dr Gulzar says it is important for those diabetics who are fasting to get a well-balanced suhour — the predawn meal — as this sets their metabolism for the day.

“A balanced diet is recommended: 45-50 per cent of complex carbohydrates with low glycaemic index so that the sugar is absorbed slowly, 30-35 per cent of protein and 20 per cent of fat is advised,” recommended Dr Gulzar.

The main meal is the suhour as one is beginning the day with it. Dr Farouqi added that the eating window during the summer Ramadan is shortened as it begins at 3am and ends before dawn and starts again late in the evening. In effect, the eating window shrinks from 7.30pm to 3.30am. The individual needs to make sure he or she gets the right nutrition in this period and adequate water and rest too.”

For the predawn meal, Dr Gulzar advised having complex carbohydrates (foods that get absorbed and assimilated slowly by the body giving a feeling of fullness for long) such as whole grains, good quality protein from white meat, fish, eggs or dairy. One needs to have a handful of mixed nuts and avocado since healthy fats in nuts and avocados give one their stipulated daily nutrition from fat. So, one can have an omelette with vegetables and a multigrain bread toast or Arabic bread, avocado and sprout salad.

“Avoid caffeine during suhour as it is a diuretic, and skip spicy foods as these are bound to make you feel thirsty during the day,” advised Dr Gulzar.

Hydration

Dr Farouqi advised diabetics taking the new-age SGLT2 (sodium-glucose co-transporter 2) inhibitors to be well-hydrated. “This medication blocks sugar absorption in the intestines and flushes it out with the urine so the kidneys need lots of water to expel the sugar. It is important that diabetics using this medication keep this in mind and ingest a lot of water during suhour or better have the medicine after iftar.”

Dr Gulzar added: “Apart from the new diabetic medications, some blood pressure medications have diuretics and can cause further water loss. People on these medications should consult with their doctors as to adjust the timing and dosage during Ramadan.”

Iftar meals

Since the iftar period is longer, Dr Gulzar advises breaking up the meal — from appetisers to main course and salads and bread/rice/pasta later. “It is better to consume a small meal for iftar and then have dinner later, rather than having a large meal (as one tends to overeat when they are very hungry).

“Avoid excess sweets and oily foods specially when breaking the fast. Hunger causes one to crave for sugars and carbs and avoiding indulging in it can promote a balanced insulin-glucose metabolism,” he advised.

For appetisers, it is always advisable to end fast with a date and some water. Diabetics can check their blood sugar before ending the fast and decide if they require to eat more. However, this is usually enough for the patient to be stable. Then this can be followed by a light clear soup which is lentil- or plant-based or clear chicken soup and a salad. The body needs time to acclimatise to food after a long gap, so it is important not to overload the digestive system.”

For the main course, one can have grilled meats, a small portion of bread/dense carbohydrate like a whole grain pasta or Arabic bread and a salad. Desserts should be avoided and at best anything non-dairy and non-sugary can be had in a small portion such as a piece of fruit.

Exercise

Dr Gulzar also advised that two hours after ending fast with a light snack, people are advised to indulge in moderate exercise such as a brisk walking, or low-intensity cardio workout before settling for the big meal.

“This will not only kick-start your metabolism but also regulate body temperature and help one work out the excess calories one may have consumed as individuals tend to overeat. Besides, exercise is important as people tend to sleep and rest a lot during the day.”

Medication

Medicine doses for diabetics need to be calibrated and their timings and dosage tweaked to suit the new eating pattern during Ramadan.

“One must never stop taking medications because of fasting during Ramadan,” said Dr Gulzar. “It is advisable for diabetics intending to fast to get a complete blood work done and understand the needs of their body.”

Dr Gulzar added: “Oral medications are generally given after iftar but most patients have prescriptions made on a case-by-case basis and it is best to consult with one’s own doctor as to the timing of medications during Ramadan.”

 

Which categories of diabetics can fast?

The International Diabetes Federation (IDF) has categorised diabetics into high risk, medium risk and low risk for purposes of understanding who can fast. It is not recommended that those with Type I diabetes to observe fast. In the Type 2 category, the IDF has created sub-categories of people who can or cannot fast.

High risk are those:

  • With high HbA1c levels of 9 and above;
  • Who require insulin injections;
  • Who have diabetic ketoacidosis (breakdown of fat for energy as cells are starved of sugar due to impaired sugar metabolism and sugar remains in blood). Ketones are excreted through the urine;
  • With a history of fluctuating high or low blood sugar episodes (hyperglycaemia or hypoglycaemia); and
  • Who may have a host of other diabetes-related complications such as neuropathy, retinopathy, cardiovascular disease or chronic kidney disease and require constant monitoring.
  • This category of people can fast only under strict medical supervision and if something goes wrong, the patient needs to break the fast immediately or seek medical help.

Medium risk are those:

  • Who may be insulin or pill dependant;
  • Who are obese and do not exercise at all;
  • Who have bouts of hyperglycaemia or hypoglycaemia; and
  • Who have HbA1c levels of 7-8.
  • Usually, people in this category are able to observe the fast with a proper review of their health prior to the holy month.
  • Low risk who are usually allowed to fast are those:
  • Patients on low dosage of diabetic pills and can withstand altering of pill and meal times;
  • Who exercise regularly and are not obese;
  • Who are able to maintain their weight with balanced nutrition and cardio exercises; and
  • Who have an HbA1c level of 6.5 or less.

These patients are able to improve their health with the correct guidelines and abstinence during Ramadan.