Ramadan and diabetes – part three: Fasting and special categories of patients

Diabetes type 1

Patients with type 1 diabetes are advised not to fast due to the risk of severe complications. However, recent research involving young adults suggests that if the patient is stable, otherwise healthy, has good awareness of hypoglycemia, and is well monitored, fasting may be possible. One study involving 33 adolescents with type 1 DM found that 60.6% of patients practiced fasting without serious problems. These adolescents and their parents had intensive pre-Ramadan education on nutrition, adjusting insulin and self-monitoring of blood glucose. A total of five cases of mild hypoglycemia and no cases of diabetic ketoacidosis were recorded. However, some episodes of hypoglycemia go unrecognized, suggesting that regular self-monitoring of fasting blood glucose is vital.

Although the results of these studies are encouraging, they cannot be generalized to all people with type 1 diabetes. Strategies to prepare these diabetics who choose to fast include: medical education focused on fasting during the month of Ramadan, medical assessment including assessment of awareness of hypoglycemia, following a healthy diet and physical activity, modification of the insulin regimen and frequent self-monitoring of blood glucose.

Elderly people

Many older people have been fasting during the month of Ramadan for many years and should not be categorized as high risk based on their age, but based on their health status and social circumstances. Many older people, especially those who have been diabetic for many years, will have comorbidities that affect the safety of fasting. It is necessary to perform an assessment of functional capacity because age in itself is not considered an additional risk factor for fasting. The choice of antidiabetic drugs that carry different risks for hypoglycemia should also be considered.

Pregnant women

Three quarters of pregnancies overlap with the month of Ramadan, and the risk to the mother and fetus exempts pregnant women from fasting. However, many women will choose to fast.

The risk categories take into account the differences between pregnancy with pre-existing diabetes and gestational diabetes mellitus (GDM). Some important factors to consider include:

• Pregnancy with existing diabetes affects the pregnant woman during the entire duration of pregnancy, compared to the relatively shorter duration of gestational diabetes in which pregnancy normally occurs during the first or second trimester.
• The type of antidiabetic drugs used by diabetic women before pregnancy: incretins or thiazolidinediones are considered relatively low-risk in terms of safety for fasting. However, during pregnancy, the vast majority of women with DM type 2 are treated with insulin, metformin or glibenclamide. Insulin and glibenclamide carry a higher risk of hypoglycemia if the pregnant woman is fasting.
• Many are concerned about hypoglycemia in Ramadan, however, for pregnant women, hyperglycemia is associated with increased risk for both mother and fetus. For this reason, pregnant women with pre-existing diabetes or GDM are advised not to fast until additional research data are available to support any change in risk category.