Are you living with diabetes and planning to fast for Ramadan? Follow these practical tips and advice so you can enjoy a safe and healthy Ramadan.

Consider your risk

Fasting, refraining from using medications, insulin and drinking water will affect your blood glucose levels (BGL) and can lead to potential risks including high BGL (hyperglycaemia), low BGL (hypoglycaemia or hypo), dehydration, blood clots and diabetic ketoacidosis (DKA).

According to religious tenets, fasting is not meant to create excessive hardship on an individual. It is a commendable spiritual practice but it’s one that can come with health risks for people living with diabetes. You may be advised not to fast if your diabetes management is unstable prior to Ramadan, if you have type 1 diabetes, if you are hypo unaware, pregnant, unwell, or will be performing intense physical labour.

If you have compilations associated with diabetes, such as heart disease, kidney disease or visual problems, the risk of these issues becoming worse during the fast is high, and so you should consider not fasting.

If you have type 2 diabetes and are treated with metformin, thiazolinediones or diet alone, and if your blood glucose is well managed, you are at low risk of complications with fasting.

The decision to fast is personal, and your health care team has a duty of care to respect your commitment and ensure your safety.

Be prepared

A pre-Ramadan assessment is an opportunity to review your blood pressure, BGL and lipids, learn of any potential risks of fasting, discuss monitoring and how to treat a hypo or manage high BGL, and prescribe any Ramadan-specific changes in the dose and/or timing of your medication or insulin regime.

Remember a hypo is a medical emergency and treatment means you will need to break your fast. Visiting your doctor to adjust your insulin regime before you begin fasting can help you avoid this.

Safety tip: Never stop taking your insulin or your diabetes medications. Speak with your diabetes doctor or nurse about how to change the time and dose during Ramadan.

Check BGLs regularly

Checking your BGL more frequently is encouraged during Ramadan, particularly if you take insulin or are on any sulfonylureas.

The Diabetes and Ramadan International Alliance confirm that pricking the skin for blood glucose testing does not invalidate the fast.

Safety tip: If you feel unwell at any time during Ramadan, check your BGL and be prepared to break the fast to treat a hypo (BGL less than 4mmol/L) – or manage hyperglycaemia (BGL more than 15mmol/L).

Eating during Ramadan

During the month of Ramadan your eating pattern will be affected by long gaps between meals and feasting after iftar that can lead to greater swings in blood glucose levels. Good nutrition is particularly important at this time and maintaining a healthy eating plan will help you avoid the overeating of carbohydrates and fatty foods at the sunset meal.

Suggested meal plan

• Let your predawn meal (suhoor) be the largest one
• Include complex carbohydrates such as multigrain/wholegrain, sourdough breads, porridge, oats, bran, barley, semolina and buckwheat to give you sustainable energy throughout the day
• Include protein rich foods such as lean meat, poultry, fish, eggs, dairy products, seeds, nuts, beans, legumes and tofu
• Drink plenty of fluids, and choose fluid-rich foods to make sure you are well hydrated for the day.

When breaking your fast (iftar)

• Break your fast with a ‘sunset snack’ of two dates, a cup of water and a bowl of soup. Three dates are equal to one exchange (15g of carbohydrates). This will provide an instant boost of energy and hydration to help settle your hunger and prevent overeating at the start of your main meal.
• Eat slowly and chew food well.
• Use the healthy plate model as a reminder: a quarter of your plate should be complex low GI carbohydrates such as low GI rice, legumes and sweet potato, a further quarter of your plate should be lean meat, skinless chicken, egg, fish or tofu; the final half of your plate should be vegetables or salad
• Make sure you drink plenty of fluids – try to drink two cups every hour to remain hydrated.

Snack right

Two hours after the dinner meal, it is normal to feel hungry. Have a healthy snack to avoid overeating or overindulging in traditional sweets. Avoid sugary foods as they don’t provide you with sustainable energy. Fried foods may also make you feel sluggish.

Some healthy choices include:

• One or two pieces of fresh fruit
• Canned fruit in natural juice (drained)
• Vegetable sticks with a tablespoon of hummus, tomato salsa or yoghurt dip
• 100-200g of low fat yoghurt
• A cup of low fat milk or soy milk (calcium fortified)
• 1-2 cups unbuttered and unsalted popcorn
• A handful of plain raw unsalted nuts
• A slice of grainy bread with a thin spread of avocado, low-fat ricotta, cottage cheese or hummus, with sliced vegetables.

Physical activity

You can continue to do your normal physical activity. However excessive physical activity should be avoided as this can increase your risk of hypoglycaemia, particularly during the few hours before the sunset meal.

Taraweeh (multiple prayers performed after the sunset meal which involve repeated cycles of rising, kneeling, and bowing) should be considered a part of the daily exercise program. Taraweeh can be a tiring activity and you could become dehydrated or be at risk of hypos. To avoid problems during Taraweeh, make sure you:

• Eat starchy foods with iftar as they are digested slowly
• Drink plenty of water following iftar
• Take a bottle of water and glucose treatment with you to taraweeh.

Insulin treatment

Basal (sometimes also called background insulin, long or intermediate-acting) insulin doses may need to be reduced by around 15-30%. It is best taken after iftar.

Bolus (mealtime, rapid or short-acting) insulin doses should not be taken at lunchtime. The suhoor dosage may need to be reduced by around 25-50%. Usually the regular bolus dosage can be continued at iftar, provided you have a similar sized meal as you would usually have at dinner.

If you take premixed insulin once daily the dosage can be taken at iftar. For those taking twice daily premixed insulin, the suhur dosage will need to be reduced by around 25-50%. If you are usually on three lots of premixed insulin at main meals, the lunchtime one should not be taken. The iftar and suhoor doses will need to be adjusted.

If you have type 1 diabetes and you are on an insulin pump, generally the basal rates will need to be reduced by 20-40% in the last three to four hours of fasting. You should increase your basal rates by up to 30% after iftar.  Normal carbohydrate counting and insulin sensitivity principles apply in regards to bolus doses at both suhoor and iftar.

Note: The above medication and insulin dose adjustment recommendations are a guideline only. You should always seek advice from your doctor prior to Ramadan in regards to any medication changes that may be needed.

Diabetes Educator and Accredited Practising Dietitian Shannon Lin
Accredited Practising Dietitian Lina Breik
Accredited Practising Dietitian Dyala Al Jabi