The UAE has one million people suffering from diabetes. That comprises 19.3 per cent of the total population. A National Diabetes Research Study carried out in 2014 by the Emirates Diabetes Society (EDS) indicates that nearly 25 per cent of the national population has diabetes, which means that nearly a quarter of Emiratis are diabetic.
Worldwide, nearly 148 million Muslims have diabetes.
Observing the fast during Ramadan calls for a focused approach and one must be armed with the requisite information.
The International Diabetes Federation (IDF), in conjunction with the Diabetes and Ramadan (DAR) international Alliance, has brought out a detailed booklet – Diabetes and Ramadan, Practical Guidelines.
Dr Abdul Razzak Al Madani, President of the Emirates Diabetic Society (EDS), who collaborated on the guidelines, said: “Fasting for over 14 hours has an impact on the homeostatis and endocrine processes of the body. [Homeostasis is the tendency of the body to maintain an equilibrium within its internal environment, even when faced with external changes.] It not only affects the circadian rhythms of the body, but alters sleep patterns and therefore, affects metabolic patterns of the body. So it is important for diabetics fasting in Ramadan to follow the guidelines for best results.”
Dr Mohammad Hassanain, consultant endocrinologist and chair of the DAR international alliance said: “This booklet has been created based on the collaboration between the health specialists and religious heads. The mufti of Egypt Professor Shawky Ebrahim Allam has supported this guideline. Islam does not advocate harm to the body. There is harmony between religious recommendations and doctor’s advise. For instance, it is fine to test blood sugar when you are fasting. If you are unable to fast owing to your health condition, you should break your fast and not endanger your body.”
Studies conducted indicate that most diabetics are keen to observe the fast and need healthcare professionals to guide them on the risks associated the nutritional advice and clinical guidance to be able to successfully observe it. In a study entitled, Epidemeology of Diabetes and Ramadan (EPIDIAR), carried out in 2001, it was found that 42.8 per cent people with TIDM and 78.7 per cent with T2DM fasted for at least 15 days. In another study conducted in 2010, it was found that nearly 94.2 per cent people in the group with T2DM fasted for 15 days and 63.6 of the group fasted daily. This just demonstrates the keenness people have to fast during this month.
Diabetes and Ramadan booklet attempts to answer basic queries diabetics are likely to have such as:
- What are the significant risks that diabetics are likely to have during fasting?
- What predisposes a diabetic patient to increased health risks?What are the best oral medications to have during the fast?
- What is the appropriate type and dosage of insulin during the fast?
- What is the right amount of caloric and nutritional intake requirec to fast without medical emergency?
- Who can fast?
Based on their management of the diseases, a risk stratification has been done to understand how safe it is for diabetics to fast.
Dr Mohammad Hassnain, consultant endocrinologist at Dubai Hospital and chair of the DAR International Alliance, elaborated: “Based on their risks, diabetics have been classified into the Red, Amber and Green category as an advisory to fasting. Those in the Red category can observe fast only under strict medical guidance and may have to break their fast in case of a medical emergency. Those in the Amber category can fast provided they have carried out all checks and have stable medical conditions. It is easiest on diabetics in the Green category to fast and they are ones who are able to observe all the fasts. Based on your condition, a diabetic can decide which category he falls into and evaluate himself.”
Red Category
- Those with high blood sugar fluctuations in the last three months before Ramadan.
- Acute illnesses prior to Ramadan.
- People who get diabetic Ketoacidosis (DKA) passing of ketones in urine.
- Women who recently delivered but had pregnancy with gestational diabetes.
- Poorly controlled Type 1 Diabetes.
- People with macrovascular complications such as neuropathy, retinopathy.
- Elderly diabetic with chronic ill-health.
Particularly noteworthy are diabetics who have suffered either severe hyperglycaemica (high blood sugar above 300 mgdl) or hypoclycaemia (blood sugar less than 70 mgdl) episodes in three months prior to Ramadan. “Those with blood sugar fluctuations have a higher risk as going without food and water for long hours can cause occurrence of the same episode,” said Dr Madani
Amber category
- Type 2 Diabetics with poor glycaemic control.
- Well-controlled Type 1 diabetics.
- T2D who are insulin dependent and use mixed (long- and short-acting insulin).
- Pregnant woman with T2DM or Gestational Diabetes controlled by medication.
- People with stable Chronic Kidney disease (CKD).
- People with stable macrovascular disease.
- Type II diabetics who have a job that is labour-intensive.
- T2Diabetics who follow a prescription that can cause cognitive dysfunction
Green Category
- Those on lifestyle therapy (controlling diabetes through physical exercise and balanced nutrition).
- Those on medications such as metformin and Acrabose among other second and third line of medical therapies available.
- Those who have HBA1C level between 6.5 to 7.
How to fast
Nutritional Therapy plays a very important role in fasting especially for diabetics, pointed out Dr Madani. This means that diabetics need to first determine the exact calorie requirement of their body as per their body weight and height and then divide it accordingly for suhour and iftar meals plus a couple of snacks.
Men
Calorie intake: 1,800-2,200
For weight reduction: 1,800 calories
Women (more than 150 cms height)
Calorie intake: 1,500 -2,000 or
For weight reduction: 1,500 calories
Women (less than 150 cm)
Calorie intake: 1,500
For weight reduction: 1,200 calories
Meal percentages
Suhour meal
30-40 per cent of your total caloric intake for the day
Iftar meal
40 to 50 per cent
Snacks
10-20 per cent
Example of calorie break-up
1,500 calorie diet
Suhour: 600-700 calories + 250- 200 calories for snacks
Iftar: 500- 600 calories
Dos and don’ts
Dos
Consult a doctor to assess your risk level
Check your blood glucose level frequently (which would be once before suhour, a couple of hours after suhour, then in the day time and once closer to iftar). Break your fast if your blood glucose goes below 70 mg/dl
Ensure your suhour is as late as possible and divide your medication between suhour and iftar. If on insulin get your endocrinologist to prescribe the right kind and unit of insulin required
Have food rich in fibre, high water content and avoid sweetened fruit juice
Don’ts
Do not overeat.
Avoid salty food and caffieine during suhour as it is likely to make you thirsty.
Divide your meals into two main meals, one each for suhour and iftar and two snacks during to be had once for ending the fast and one before dinner.
(By Dr Mohammad Hassanain, consultant endocrinologist).
Case study
Mena Tallah Helmy, 23, an Egyptian, was diagnosed with Type 1 diabetes, two weeks after her 5th birthday, while on a holiday in Egypt. Iitially, her parents panicked as they didn’t understand the condition at the time. She learnt about the condition and embraced the fact the she was different very early on in life and quickly grew to be comfortable with it. She learnt how to count carbs and calculate insulin at the age of seven.
With the support of her friends and family, she grew up with little restriction in terms of food and activity. To keep her diabetes in control, she frequently goes to the gym and exercises regularly, to keep fit. She believes exercise is a ‘must-do’ for everyone and aids in general well-being. “The benefits are enormous,” she says.
An advertising executive, Helmy has managed to observe Ramadan fasts for 10 years successfully.
“I always monitor by sugar levels and consult my doctor before beginning the fast. During Ramadan, my activity levels change, my meal timing changes and so do my insulin requirements which are tweaked according to the meals I have. I require a base insulin shot that is long-acting and fast-acting when I consume carbohydrates. So when I get up before the fajr prayers for suhour, I make sure I have a base shot.
“I usually have cucumber, a single date, yoghurt and bananas. I make sure I have plenty of water - at least three litres before fajr and water-based food stuff to keep me hydrated. I reserve the fast-acting insulin after maghrib prayers and once I have dinner.
“My blood sugar levels are usually 250 mgdl after suhour and go down to 70 until iftar. I check my blood sugar levels at least three times to make sure I am not falling very low. If it falls down below 60 mg/dl by 4pm, I know it will go way below so on those days, I have to break my fast. I try not to have these episodes by eating right and resting well.
“Even for iftar, I avoid fried food, have dense carbohydrates, lentil soup, beans and legumes, rice and vegetables and some lean meat. I have managed to fast in Ramadan with planning and determination.”
