Many Muslims with diabetes participate in Ramadan fasting, even against medical advice. The International Diabetes Federation (IDF) and Diabetes and Ramadan (DAR) International Alliance have developed Practical Guidelines to enhance knowledge of diabetes and Ramadan fasting, as well as empower healthcare professionals to better advice and support their patients during Ramadan.
Studies have shown that a large proportion of patients with diabetes fast for at least 15 days during Ramadan. The shift in meal times and sleep patterns during Ramadan has an effect on the homeostatic and endocrine processes in the body. For individuals with Type 1 or Type 2 diabetes Mellitus (T1DM or T2DM), fasting usually causes the breakdown of glycogen to glucose as well as the buildup of glycogen from non-carbohydrate sources. In T1DM patients, there is production of ketone bodies from the breakdown of fatty acids and certain amino acids. These processes place people with diabetes at  higher risk of low blood sugar (hypoglycemia), high blood sugar (hyperglycemia) and production of high levels of ketones (diabetic ketoacidosis) and there is evidence from several studies suggesting that these risks increase in patients who participate in Ramadan fasting. While the glucose pattern of healthy individuals before and during Ramadan has been shown to be stable, diabetic patients have individual variability that puts them at risk, and as such, an individual approach to management is encouraged.
The IDF and DAR international alliance, which is made up of experts in the field of diabetes, developed practical guidelines for managing diabetes during Ramadan. Their study is published in a recent issue of Diabetes Research and Clinical Practice. In this study, the researchers used results from published clinical studies as well as expert opinion (where evidence is lacking) to put forth recommendations for patients who participate in Ramadan fasting. The Alliance proposed three categories of risk based on up-to-date information from science and clinical practice during Ramadan. These categories are:
- Very high risk: Includes patients who experienced severe hypoglycemia, unexplained diabetic ketoacidosis and hyperosmolar hyperglycemic coma within the 3 months before Ramadan. Patients with history of recurrent hypoglycemia and those with other severe medical conditions, pregnant women with pre-existing diabetes are all included in this category. Patients in this group are not supposed to fast, however, if they decide to fast, they need to be monitored by qualified specialists and should be ready to break their fast if advised to do so.
- High risk: Includes patients with well-controlled T1DM and T2DM and stable medical conditions. Patients in this category are advised not to fast.
- Moderate or low risk category include individuals who have T2DM that is well controlled with lifestyle therapy and/or drugs. Individuals in this category may fast but need to seek medical advice before doing so.
If patients in any of the three categories decide to fast, structured education, regular blood glucose monitoring and dose adjustment of regular medications is recommended.
The IDF-DAR guidelines provide advice based on up-to-date information to health care providers and patients on whether or not patients should fast during Ramadan, depending on their risk category. For those who decide to fast against medical advice, a patient specific management plan is recommended. Although the IDF-DAR practical guidelines have been accepted by the highest official of religious law in Egypt, opinions vary in other countries thereby stressing the need for more discussion and collaboration amongst religious leaders and health care providers in the region.
Reference
Hassanein M, Al-Arouj M, Hamdy O, Bebakar WMW, Jabbar A, Al-Madani A, Hanif W, Lessan N, Basit A, Tayeb K, Omar M, Abdallah K, Al Twaim A, Buyukbese A, El-Sayed AA, Ben-Nakhi A, On behalf of the International Diabetes Federation (IDF), in collaboration with the Diabetes and Ramadan (DAR) International Alliance. Diabetes and Ramadan: Practical guidelines. Diabetes Res Clin Pract. 2017 Apr;126:303-316. doi: 10.1016/j.diabres.2017.03.003
Written By:Â Asongna T. Folefoc
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