Dubai: Can diabetics still fast during Ramadan amid the coronavirus pandemic? Doctors say yes those with type two diabetes can fast under guidance with regular glucose monitoring and the right food choices.
Type two diabetes is a lifestyle triggered disease where glucose metabolism is impaired due to the inability of insulin - the sugar metabolising hormone - to transport sugar to cells to be converted into energy. Blood sugar levels remain high and eventually damage organs. The condition can be managed by both pills, insulin and the adoption of a healthy lifestyle.
A 2010-study found that 92.4 per cent of type two diabetes patients were able to fast for 15 days and 63.6 per cent could complete the full 30-day fast.
Mohammad Al Mazrouie, 40, an Emirati engineer in an oilfield off Abu Dhabi has fasted since the age of eight and didn’t stop despite being diagnosed with diabetes aged 40.
“I never stopped fasting because of my diabetes and following my doctors istructions I adjust my medicine dose,” he said. “For Suhoor, I make sure I have a lot of water, some yoghurt with cucumber and vegetables and late for iftar, I chose a healthy meal and small portions, but make sure I get my favourite foods as well, I have my main medication in the evening and I have always noticed that my diabetes levels have always improved after Ramadan,” added Mazrouie, who has brought down his HBAIC levels from 13 to 6.5 with sensible eating and exercise.
Diabetics can fast with support
Dr Hamed Farooqi, consultant endocrinologist and director of the Dubai Health Authority (DHA)–run Dubai Diabetes Centre (DDC) said, “International studies have indicated that fasting can have a therapeutic effect and build the body’s immunity.”
But what about about the coronavirus pandemic? Well the Diabetes and Ramadan (DAR) International Alliance has come up with two basic recommendations during COVID-19.
Firstly, the risk of contracting the virus is the same for a diabetic as it is for a non-diabetic, and second, if a diabetic tests positive, they may not cope well, because when blood sugar is high, the body’s ability to fight infections is compromised.
If the patient has other co-morbidities that may also have an adverse effect.
“According to a recent fatwa issued by clerics, even COVID-19 patients can fast under doctor’s guidance and a nasal or throat swab taken during Ramadan will not amount to breaking your fast,” said Farooqi.
Nutrition is important
Diabetics need to understand key factors about nutrition and hydration when observing the fast, added Farooqi.
“The main meal of the day is suhour or the pre-dawn meal,” he said. “That is the time a diabetic needs to check his blood glucose, decide the dose of insulin or medication he needs to take before having the meal. The eating window is shortened from 7.30pm to 3.30am,” he added. “Diabetics need to make sure they have a balanced meal that can be split into smaller portions for better sugar absorption.”
Dr Siby Elias, specialist in internal medicine, Right Health Clinic, Al Khail Gate, added, “A balanced diet would mean 45-50 per cent of complex carbohydrates with low glycaemic index (choosing dense foods that slowly release sugar into the blood and do not cause spikes), 30-35 per cent of protein ingesting both animals and plant protein intermittently and 20 per cent of fat derived from nuts seeds, healthy Omega 3 rich oils and oily fish. The individual needs to make sure he or she gets the right nutrition, adequate fibre adequate water and rest too.”
Diabetics can be either on insulin injection or oral medication and they must consult their doctor before commencing the fast.
“Most blue collar workers who are diabetic can fast under proper medical advise,” said Dr Elias. “Many work even during the sterilisation period, and are involved in manual labour and are on insulin injections. During this period when their food quality is reduced, we usually lower the insulin dosage as well as they tend to be hypclycaemic (low blood sugar) in the morning.”
Dr Farooqi advised diabetics taking the new-age SGLT2 (sodium-glucose co-transporter two) 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.”
Those taking renal or blood pressure medication must also regulate their doses during Ramadan as these medicines are diruetics and could cause electrolyte imbalance in a fasting diabetic, he added.
Suhoor and Iftar meals
It is advisable to choose whole grain, high fibre, low glycameic index foods for suhoor such as sugar free cereals of oats or whole wheat porridge with skimmed milk or a boiled egg and whole grain bread sandwich with hummous and greens along with a fruit and yoghurt smoothie for breakfast, advised the doctors.
In the evening there are ample hours and diabetics must choose to end the fast with a light meal, exercise and then go for a larger meal during dinner time.
“First it is important to test the blood sugar and decide on the quantity of food one can have. Ending the fast with a couple of dates, water followed by a clear lentil and vegetable or chicken soup should be enough,” added Farooqi.
For the main course diabetics must have one portion of cooked vegetable such as leafy vegetables, mushrooms, potato, beans, cauliflower, a raw salad, one portion of bread or rice, one portion of lean meat that is grilled or panbroiled and one portion of dairy such as cottage cheese or yoghurt, said Dr Elias.
Absolute no no
Diabetics should refrain from large portioned meals, cut out refined carbohydrates such as pastries, cakes, puddings and fried food such as samosas and cutlets, carbonated and sweetened drinks form their meals.
“It is advisable to avoid, refined flour, sugary desserts. Only a small portion of carbohydrates must be had in the night. During the entire fasting period it is advisable to cut out caffeine in tea and coffee or any carbonated drinks which have a diuretic effect and dehydrate a person,” said Dr Elias.
One hour after iftar, diabetics are advised to get moderate exercises before they have a big dinner. Dr Farouqi said in days of lockdown people had to be inventive and devise ways to do work outs at home.
“These days people are innovative and have run marathons on their balconies or backyards or work out with guided videos,” said Farooqi. “It is advisable for diabetics to decide on a simple mode of workout at home. Being confined to home is no excuse to get sedentary. Once exercise is over, dinner can be had by 9 pm,” he added.
Sleep cycle needs to be regulated
Since people arise earlier than normal their sleep patterns have to be readjusted and it is important diabetics get adequate sleep.
“It is important to establish a proper sleep schedule during Ramadan and stick to it. Eight hours of sleep is recommened,” said Dr Elias.
How can diabetics know if they can fast?
Based on their HBA1C readings DAR has categorised diabetics in to high, low and medium risk. Those in the high risk are advised against fasting and medium risk people can fast under medical guidance whereas most low-risk diabetics can easily observe the 30-day fast with minor tweaks to their lifestyle.
What is HbA1C?
HbA1c or glycosylated haemoglobin is an indicator 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 to 5.5, it is about 5.5 to 6 in pre-diabetics and in cases of people with diabetes, the HbA1c reading can be anything beginning from 6 up to 14. The higher the HbA1c the more severe is the diabetic condition of the patient.
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)
- 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 ( high blood sugar) or hypoglycaemia ( low blood sugar); and a 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
- 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