It’s about time to welcome the holy month of Ramadan. Fasting during Ramadan is an obligatory duty for all healthy adult Muslims and it is considered as one of the five pillars of Islam. It is estimated that there are 1.1 to 1.5 billion Muslims worldwide, comprising 18–25% of the total world population and every year about 40 to 50 millions of diabetic patients across the globe observe fasts in the holy month of Ramadan. In their pursuit to gain Allah’s nearness, they have to face quite a few more obstacles than the rest of us. And since the fasting is about 15-16 hours long this time of the year, the patients might suffer from many serious complications like hypoglycemia, hyperglycemia, ketoacidosis, dehydration, thrombosis etc., if everything is not handled properly.
So while observing fasts, the glycemic control of the patient, treatment method and presence of other illnesses are to be taken into consideration. Before anything else, let’s classify the diabetic patients into different groups to see who falls into which risk levels:
1. Very High Risk Group:
- Patients with highly uncontrolled blood glucose level.
- Those who have suffered from severe hypoglycemia (low blood sugar) or ketosis or hyperglycemic coma within the last 3 months.
- Those whose blood glucose levels often fall very low.
- Type-I diabetic patients.
- Diabetic patients with chronic kidney disease who need dialysis.
- Pregnant and lactating mothers.
- Extensive physical workers.
2. High Risk Group:
- Patients with regular blood sugar level from 8.3-16.7mMol/L, or HbA1c level 7.5-9.0%
- Those who have impaired kidney functions.
- Patients having diabetic associated vascular impairments.
- Patients who are being treated with insulin or sulfonylureas.
- Older patients.
- Patients with other associated illnesses.
3. Low Risk Group:
- Patients treated with short acting secretogogues.
4. Very Low Risk Group:
- Patients whose blood glucose level is in full control by means of their change in diet habit alone, or metformin, or thiazolidinediones.
It is important for the diabetic patients to undergo a full physical assessment before Ramadan kicks in in order to see if you’re fit to observe your fast. Diets, type of drugs and daily routines are preferably to be set by your physician’s advice. If convenient, you should consult with him/her regularly throughout the holy month.
Things you’ll have to keep in mind during Ramadan:
- Keep track of your blood sugar: Measure your blood glucose level regularly 2 hours after suhoor and 1 hour before iftar. You should also check it whenever you feel too weak. If the reading in the glucometer is too low, you might want to break your fast.
- Diet habit: It’s better for the diabetic patients to be the last one to finish suhoor and first to start iftar. The amount of food taken in suhoor should be similar to what is eaten during lunch. Iftar is better taken intermittently in small amounts. Taking a light meal in between 10 to 11 at night is a healthy practice for people with diabetes. Low glycemic foods like brown rice, whole grains, cereals are better suited for them. They ensure sustained slow release of glucose in the blood stream. High calorie foods like sweetmeats, syrup, soft drinks and junk foods are best avoided. Remember, you should never observe a fast without taking your suhoor if you are a diabetic patient.
- Physical activities: Excess physical endurances are better avoided. It may cause your blood sugar to fall abruptly. Taraweeh is a very good and balanced physical exercise. But if you need more than that, it should always be done in the evening after taking iftar.
- Break the fast when necessary: Saving your own life is also an ‘Ibadah in Islam. And there’s no penalty for breaking the fast in order to do so. But you have to ensure that you break your fast when it is absolutely necessary and continuing with it can potentially harm you or even become fatal. If your physical conditions deteriorate to an extent that endangers your very life, it is advised that you break the fast. If your blood sugar level is 3.9 mMol/L in morning or 3.3 mMol/L throughout the rest of the day, it is considered critical. It is also dangerous if it rises above 16.7 mMol/L anytime during the day. In these conditions as a diabetic patient, it is definitely advised that you break the fast.
Life in Ramadan is different than the rest of the year, both spiritually and physically. Proper pre-Ramadan preparations are required to undertake the fast as safely as possible. Diabetic patients should have special treatment plans set for Ramadan. Several changes should be adapted in the treatment schedule. Here are some keynotes regarding this:
Type-I Diabetes:
The only treatment modality in case of patients with this type of diabetes is insulin. So it is highly risky for the patient to observe a fast without proper care and guidance from his/ her physician. But with permission and advice from the doctor it can be observed.
Type-II Diabetes:
Patients with type-II diabetes who can control it just by diet regulation and lifestyle modification and do not need medication are the least prone to develop hypoglycemia. They are almost completely safe to perform their fast.
It is safer to take long acting medication than the short acting ones. It helps in maintaining constant levels of blood sugar levels throughout the day. Hence, type-II diabetic patients should consult their physician before Ramadan to bring about the changes. In case of orally prescribed drugs, insulin sensitizers like, Metformin, glitazones (Rosiglitazone, Pioglitazone) are less likely to give rise to hypoglycemia.
But secretoguges like, Sulfonylureas and Meglitinides (Repaglinide, Nateglinide etc.) increase the risk of developing hypoglycemia.
Adjust your dosages:
Diabetic patients who are on drugs like sulfonylureas and biguanides are advised to change their dosages of drug after consulting with their doctors. But for those who are on glitazones need not worry about dosage adjustments.
Adjust your medication clock:
One of the important lessons of Ramadan is time management. You’ll have to apply that lesson with medications as well. You need to amend your medication schedule and stick to that the entire month.
For those who are taking oral drugs:
If you are taking just a single dose of drug each day, you’ll have to it after iftar. If you’re taking two doses, then take the first one after iftar and half of the second one after suhoor.
For those who are on Insulin:
Short acting insulin is to be administered while taking food. If one dose of insulin is what you take each day, you’ll have to take that during iftar. If you’re on two doses, take the first one during iftar and half of the second one just before suhur. If you have to take three doses, take the first one during iftar, the second one after a few hours and the third one just before suhoor.
Ramadan is the month of purification and rectification. So everyone who wants to fast to purify himself and get closer to his creator, this month is definitely the time to take advantage of. Diabetic patients are not an exception to this. But diabetic patients’ decision to fast should be made after ample discussion with his or her physician concerning the risks involved. They should undergo pre-Ramadan assessments and receive appropriate education and instructions related to physical activity, meal planning, glucose monitoring, as well as dosage and timing of medications during Ramadan. Also close follow-ups of the patients by the family members is essential to reduce the risks related to development of complications related to fasting.
