If I have diabetes can I fast? 

Fasting is a commendable spiritual practice. But it does come with associated health risks for people living with diabetes. People living with type 2 diabetes who are treated with metformin, thiazolinediones, or diet alone and who have good blood glucose control are at low risk of complications with fasting. However, people living with type 1 diabetes and/or any person using insulin or oral sulphonylurea medications have a greater risk of fasting-related complications. According to religious tenets fasting is not meant to create excessive hardship on the individual. The sick, elderly, pregnant, or breastfeeding are exempt from fasting.

What is a pre-Ramadan healthcare assessment?

A pre-Ramadan medical assessment with your diabetes health care team before Ramadan is advisable. This assessment is used to assess your level of safety for fasting during Ramadan and may include recommendations to change your medication during the period. In addition, you will be given education about the signs and symptoms to watch out for, that may indicate you need to break your fast for safety reasons. It is particularly important for health care professionals to provide individualised advice to you prior to Ramadan as energy (kilojoule) restriction leads to greater insulin sensitivity.

Key questions to ask your diabetes healthcare team prior to Ramadan

• What are the signs and symptoms of hypoglycaemia?
• Do I need to change my medications during Ramadan?
• What are signs that the fast should be broken?
• How often should I check my blood glucose levels?
• Do I need to check in with my healthcare team during Ramadan?
• Do I need a sick day management plan (type 1 diabetes/type 2 diabetes)?

What happens in your body when you fast?

When you eat food containing carbohydrates they are digested in the stomach and glucose is sent to the bloodstream. As glucose is entering the bloodstream the pancreas releases a hormone called insulin. Insulin’s job is to allow glucose into the cells where it can be used for energy.

When we don’t eat for a while, a hormone called glucagon begins to increase. This leads to some of the stored glucose from the liver and muscles (called glycogen) to be released back into the blood for the body to use where it needs it for energy. This helps to ensure there is a steady supply of glucose available and keeps your blood glucose levels from going too low. Once the stored glucose runs out, your body moves on to using stored fat for energy. During the process of fat-breakdown a bi-product is produced called a ketone. In some cases, if your body continues to use its fat stores for energy, ketones can be produced and this may lead to a condition called ketoacidosis. This can affect your organs due to the acidosis (imbalance in electrolytes caused by ketones). This is more likely for people living with type 1 diabetes.

Can I check my blood glucose levels when I fast? 

Yes, checking your blood glucose levels doesn’t invalidate the fast. Monitoring your blood glucose levels is especially important when fasting to detect if you are experiencing high (>15mmol/L) or low (<4mmol/L) blood glucose levels. If you experience hypoglycaemia (hypos), or your blood glucose levels are less than 4mmol/L, the fast must be broken immediately as your blood glucose levels can continue to drop. Glucose is your brain’s key source of energy, without it the rest of your body can’t continue functioning.

Why does fasting increase the risk of hypoglycaemia, hyperglycaemia and dehydration for people with diabetes? 

Sometimes when you are fasting stored glucose may fail to be released rapidly enough when needed, and hypoglycaemia can occur. Certain medications and/or insulin can also be a risk factor for hypoglycaemia. If you feel the symptoms of a hypo, you must break your fast immediately.

In other instances, some people with diabetes do not produce enough insulin, or their cells have become resistant to insulin, which means that not enough glucose is moved into the cells from the blood. This leads to hyperglycaemia. You can also develop hyperglycaemia during a fast if you do not take the correct amount of medication or insulin, are less physically active than normal, have larger than usual portions of carbohydrates, or are sick, unwell, or stressed. You may be able to lower high blood glucose levels through rest, rehydrating with unsweetened fluids such as water and, if you feel well enough, doing some gentle exercise. If your levels remain at 15 mmol/L or higher for more than 24 hours, and especially if you are unwell, you should seek advice from your health care team.

Fasting also increases your risk of dehydration in addition to having high blood glucose levels (hyperglycaemia). Hyperglycaemia can make dehydration even worse, which may increase blood viscosity which in turn can lead to life-threatening conditions.

Can I exercise during Ramadan? 

Regular or light physical activity may be maintained. Excessive physical activity increases the risk of hypos and dehydration.

Do I need to have Suhoor (pre-dawn meal)? 

Yes, it’s narrated that Anas ibn Maalik said the prophet (peace and blessings of Allaah be upon him) said: “Eat Suhoor, for in Suhoor there is blessing.¹’’ Long hours without eating can increase your risk of hypos so it is recommended to have something to eat before sunrise to balance your blood glucose levels. Let Suhoor be your largest meal.

What types of foods can I eat for Suhoor? 

• Include complex carbohydrates to give you sustainable energy throughout the day. These include multigrain/wholegrain, sourdough bread, porridge, oats, All-Bran, barley, semolina and buckwheat
• Include protein-rich foods such as lean meat, poultry and fish, eggs, dairy products, seeds and nuts, beans and legumes and tofu
• Drink plenty of fluids, and choose fluid rich foods to make sure you are well hydrated for the day

What types of food should I eat when breaking my fast (iftar)? 

1. Break your fast with a date, a cup of water, and or a bowl of soup. Give yourself 10 to 15 minutes to go and pray. This will provide an instant energy boost and help settle your hunger and prevent overeating at the start of your meal.
2. Make sure you drink plenty of fluids. Try to drink two cups every hour to remain hydrated.
3. Eat slowly and chew food very well to help develop mindfulness around eating.
4. Use the healthy plate model and fill a quarter of your plate with complex low GI carbohydrates such as pasta, low GI rice, legumes and sweet potato, a further quarter of the plate with lean meat, skinless chicken, fish, eggs or tofu and half the plate with vegetables or salad.

Snacking two to three hours after (iftar) the dinner meal

Snack right two to three hours after iftar to avoid overeating when you break your fast and to prevent overindulging in traditional sweets after. Avoid sugary foods as they don’t provide you with sustainable energy and avoid fried foods as they can make it difficult to manage blood glucose levels.

Some healthy choices include:

• 1-2 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)
• 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, and sliced vegetables

Does getting a covid vaccine during Ramadan invalidate the fast?

No, getting the covid vaccine during Ramadan does not break your fast.

Where to go for more diabetes information and support?

• Call our contact centre on 1800 177 055 and ask to speak to a healthcare professional for information and support.
• Find a local credentialled diabetes educator here or an accredited practising dietitian here.
• DaR SaFa – an app containing a Ramadan nutrition plan for diabetes, and frequently asked questions about diabetes and nutrition.

References

1. Riyad as-Salihin (1229), The book of virtues, Book 8, Hadith 239 https://sunnah.com/riyadussalihin:1229

• https://www.racgp.org.au/getattachment/cbebef7d-9738-4dc8-af85-b822ecbd164b/Diabetes-management-during-Ramadan.pdf.aspx

Updated 16 March 2023