Diabetes management and fasting safely during Ramadan

Morgan Liotta

12/04/2021 12:29:16 PM

To help avoid risks while maintaining compliance with religious practices, patient education is the cornerstone of managing diabetes during Ramadan.

Female Muslim patient with young child
GPs can help to ensure fasting is carried out safely during Ramadan while still respecting religious practices.

All healthy adult Muslims are obliged to fast from sunrise to sunset during the month of Ramadan, which this year is observed 12 April ­– 12 May.
As per the Quran, exemptions from fasting include:

  • people with acute and chronic illness, includes diabetes type 1 and 2
  • people with mental illness
  • elderly people
  • women who are breastfeeding/pregnant/menstruating
  • pre-pubescent children
  • people who are travelling.
However, according to the RACGP’s Management of type 2 diabetes: A handbook for general practice (diabetes handbook), many people with diabetes still choose to fast during Ramadan.
The metabolic nature of diabetes means these people are at greater risk of complications from marked changes in food and fluid intake.
The diabetes handbook, which includes a new section on diabetes management during Ramadan, outlines the main concern is risk of hypoglycaemia.
‘Fasting can disrupt normal glucose homeostasis and lead to serious consequences. Patients who choose to fast should be warned of these complications,’ the handbook states.
‘Because eating patterns can vary significantly from person to person during Ramadan, GPs should develop individualised plans for insulin use for each patient.’
Dr Devendra Kawol is a GP who wrote the Ramadan section of the handbook. He told newsGP that some Muslim people with diabetes may prefer to discuss fasting during Ramadan with their local imam rather than their GP.
‘GPs should be aware to ask Muslim patients specifically if they intend to fast,’ he said. ‘When they hear it from a local imam, they would comply better.
‘Pre-Ramadan diabetes education is very important and as per new guidelines, risk stratification is equally as important … as is cultural sensitivity.’
Dr Kawol recommends GPs discuss glucose monitoring, fluids, diet intake and physical activity, and provide education regarding medication adjustments and recognition of red flags such as hypoglycaemia and hyperglycaemia.
‘All patients should break their fast if their blood glucose is <3.9 mmol/L and >16.7, they develop symptoms of hypoglycaemia, hyperglycaemia, dehydration or acute illness/cardiac symptoms,’ he said.
‘Medication use and adjustments can be directed by practical guidelines. For diet, [advise patients to] modify carbohydrate intake and loads to avoid post-prandial hyperglycaemia.
‘Post-fasting fluid intake should also be maintained, as well as normal physical activity, but avoid strenuous exercise.’
Blood glucose monitoring is allowed during Ramadan and does not constitute ‘breaking the rules’, Dr Kawol said.
The diabetes handbook cautions that fasting should be ‘actively discouraged’ for people who fall into high- or very high-risk groups. High-risk groups include people with:
  • severe or recurrent episodes of hypoglycaemia in the three months before Ramadan
  • a history of recurrent hypoglycaemia
  • a history of hypoglycaemic unawareness
  • poor glycaemic control before the month of Ramadan
  • diabetic ketoacidosis episode or hyperosmolar hyperglycaemic state within three months before Ramadan
  • acute illness and comorbidities such as chronic kidney disease
  • pregnancy with pre-existing diabetes or gestational diabetes treated with glucose-lowering medication
  • poorly controlled type 1 diabetes.
Dehydration can also be a risk, particularly when Ramadan falls in summer months, due to the higher temperatures and the greater number of daylight hours.
Although fasting is not recommended for those who fall into the high- to very high-risk categories, Dr Kawol said the majority of patients with type 1 and 2 diabetes would still prefer to fast.
‘[They] enjoy the spiritual mood of Ramadan,’ he said. ‘But clinical education pre-Ramadan is crucial.’
For people with type 1 diabetes, the majority are treated with basal bolus insulin regimens.
‘If [people with type 1 diabetes] insist on fasting, GPs can seek advice from a diabetes educator or endocrinologist,’ Dr Kawol said.
‘Advise patients to reduce basal rate if on pump by 20%, and that they can still do continuous glucose monitoring.
‘Adjust the bolus dose as per carb counting for morning and evening meals and continue monitoring.’
A post-Ramadan GP assessment for patients with diabetes is also recommended, including self-monitoring of blood glucose, discussing medication and regimen adjustments, and assessing how the patient handled the fasting during Ramadan.
Patients should also be made aware that fasting safely one year does not guarantee that they can fast safely the next, or lower their risk for the next Ramadan, due to the progressive nature of diabetes.
In addition to the diabetes handbook, the RACGP has produced a fact sheet on diabetes management during Ramadan.
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