Ramadan and diabetes – first part: Effects of fasting on metabolism in diabetics

The month of Ramadan is the ninth month of the Muslim calendar, and the daily fast that accompanies it is one of the five pillars of Islam. Fasting during Ramadan is compulsory for all healthy Muslim adults, with exemptions for people with serious medical conditions, including many with diabetes. Estimates say that there are 148 million Muslims with diabetes in the world. However, most individuals with diabetes find fasting to be a deeply meaningful, spiritual experience, and most will fast, sometimes against medical advice. The International Diabetes Federation (IDF) has described diabetes as “one of the greatest global health emergencies of the 21st century”. This global epidemic includes countries with significant Muslim populations, where the prevalence of diabetes is well above the global average.

The Epidemiology of Diabetes and Ramadan (EPIDIAR) study conducted in 2001 found that 43% of patients with type 1 diabetes fasted at least 15 days during Ramadan. The 2010 CREED study reported that 94% of patients with type 2 diabetes fasted at least 15 days, and 64% fasted every day.

Due to the metabolic nature of the disease, patients with diabetes are at particular risk of complications due to marked changes in food and fluid intake. Potential health hazards include hypoglycemia, hyperglycemia, dehydration, and acute metabolic complications such as diabetic ketoacidosis; the risk for thrombosis is also increased.

The main risks, hypoglycemia and hyperglycemia are already known challenges that people with diabetes face every day; however, research has shown that fasting can increase the frequency of these events. In addition, meals eaten during Ramadan are often heavy and contain fried and sweet foods that can have an impact on blood glucose control. Fluctuations in blood glucose levels, especially postprandial hyperglycemia, are associated with oxidative stress and platelet activation, as well as with the development of cardiovascular diseases in people with diabetes. Considering all these risks, it is easy to see why religious precepts, as well as medical recommendations, allow exemptions from fasting for some people who have diabetes. However, for many people fasting is a deeply spiritual experience and they will insist on fasting, perhaps unaware of the risks. Healthcare professionals who care for these patients must be aware of the potential danger and need to quantify and stratify the risk for each individual patient in order to provide the best possible care.

It is estimated that there are more than 100 million people with diabetes who fast during the month of Ramadan, and that number will continue to grow. The latest predictions from the International Diabetes Federation (IDF) suggest that in the Middle East and North Africa region alone, the number of people with diabetes will double from 35.4 million to 72.1 million in the next 25 years.

The recommendations of medical associations for the treatment of diabetes during Ramadan categorize people with diabetes into risk groups – very high risk, high risk, moderate risk and low risk. These risk categories were supported by the Islamic Organization for Medical Sciences and the International Islamic Fiqh Academy, which published a decree on the acceptance and approval of risk categories and made recommendations for those who should not fast based on the likelihood of harm.

There is a clear need to provide a level of flexibility to help an individual with diabetes make a decision about fasting during the month of Ramadan. Patients should not fast if the likelihood of harm is high. However, if high-risk patients choose to fast, against medical advice, then the recommendations include conditions that these individuals must meet. Patients who insist on fasting must be aware of the risks associated with fasting and techniques to reduce that risk. It is also worth emphasizing that the initial risk assessment may change over time according to a number of factors. For example, a diabetic patient with poor glycemic control is considered at high risk. If control improves before Ramadan, and the therapy does not include more insulin injections, such a person will be considered to be at moderate risk. Once the patient has become aware of the risks associated with fasting, they should be provided with an individualized plan and informed of the measures they can take to minimize these risks. This includes a pre-Ramadan check-up with an internist/diabetologist, regular blood glucose monitoring, medication adjustments and advice on diet and exercise.

The cornerstone of diabetes treatment is patient education, which should include information about risks, glucose monitoring, diet, exercise, and medications.

Pre-Ramadan education provides an opportunity to remind patients of the importance of diet and exercise, and that regular glucose monitoring is necessary to avoid complications (blood sampling does not invalidate the fast).

Education of doctors in all countries of the world is also needed. A study in France found a lack of medical understanding of fasting among general practitioners resulting in suboptimal therapy and advice.