Ramadan fasting and diabetesBMJ 2007; 335 doi: https://doi.org/10.1136/bmj.39323.573148.BE (Published 20 September 2007) Cite this as: BMJ 2007;335:613
- Aziz Sheikh, professor of primary care research and development1,
- Sunita Wallia, research dietician2
- 1Division of Community Health Sciences, GP Section, University of Edinburgh, Edinburgh EH8 9DX
- 2Division of Community Health Sciences: Public Health Sciences, University of Edinburgh, Edinburgh EH8 9AG
- Correspondence to: A Sheikh
- Accepted 17 August 2007
A 45 year old Pakistani man with type 2 diabetes mellitus consults to discuss how he might fast safely during Ramadan.
What issues you should cover
Explore his motivation—whether he wants to fast (as most will) or whether he is looking for a “legitimate” exemption from fasting on medical grounds. A diagnosis of diabetes does not confer an automatic exemption, so if the second scenario is suspected it needs to be explored with sensitivity.
Although everyone agrees on the need to avoid food and drink during daylight hours, a range of views exists on the use of drugs. Ask his opinion on the use of oral and injectable drugs when fasting.
Find out how long the fast will last. The length of the fast varies according to the time of year in which Ramadan falls. Ramadan starts on about 12 September this year and in the United Kingdom the fast will be about 13 hours at the start of the month and 11 hours at the end of the month. If Ramadan falls in the summer, fasts can last for more than 18 hours, in which case fasting for people with diabetes can prove more challenging.
Inquire about his current treatment regimen, glycaemic control, and comorbidities. Achieving good glycaemic control before Ramadan will make it easier to maintain control while fasting. People taking drugs may need to change their regimens.
If he has some experience of fasting with diabetes, find out how he fared and if he has any specific concerns.
Find out whether he has sought religious advice. If fasting is medically detrimental, he needs to know that he is exempt. Some people may want reassurance from religious authorities when deciding not to fast.
What you should do
Explain that the decision is ultimately his, but that you can advise him and help him maximise his chances of fasting safely. Most people with well controlled diabetes should be able to fast, but if fasting is judged unsafe (in those with brittle diabetes or cardiac or renal complications (or a combination)), clearly communicate this. Most people will be receptive to such advice, even if they choose to ignore it.
Encourage him (ideally with input from a dietician trained to deal with cultural issues) to eat foods that are high in dietary fibre (such as whole grains, fruits, and vegetables) and have a low glycaemic index (such as beans and pulses) at the pre-dawn (Suhur) and sunset (Iftar) meals to promote glycaemic control. Discourage him from eating foods with a high glycaemic index (such as more than three dates, which are traditionally used to break the fast) until about half an hour after taking drugs to minimise sharp rises in blood sugar at sunset.
If blood glucose is well controlled by diet alone, advise him that fasting is safe.
Self monitoring of blood glucose is essential for safe fasting in patients taking antidiabetic drugs, particularly before and after the pre-dawn and sunset meals. It should guide the individual tailoring of treatment regimens described below.
To minimise the risk of hypoglycaemia, advise patients taking oral hypoglycaemic agents as follows:
o If taking a long acting sulphonylurea, switch to a short acting preparation or metformin, or both
o If a single daily dose is used, take this with the sunset meal
o If two or three doses are taken each day, take half the normal evening dose before dawn and the normal morning (and any midday) dose after sunset.
Advise patients taking insulin as follows:
o If a once daily dose is used, switch to a twice daily regimen
o If a twice daily regimen is used, take half of the evening dose before dawn and the normal morning dose after sunset
o If basal bolus insulin is used, reduce the long acting component to two thirds of normal, split into two equal doses taken during the sunset and pre-dawn meals. Take the rapid acting component as before, but omit the middle dose.
Emphasise the need to carry dextrose or glucose tablets at all times to treat hypoglycaemia; explain the importance and legitimacy of breaking the fast in emergency situations.
Encourage moderate exercise.
Arrange for a review one week into Ramadan or earlier if concerns arise.
Health Scotland. Focus on diabetes: a guide to working with black and minority ethnic communities in Scotland living with long term conditions. www.nhsggcequality.co.uk/equality/mainmenu/home/pdf/focusONdiabetesmar07.pdf
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Sadiq A. Fasting: sacred ritual, modern challenges. In: Sheikh A, Gatrad AR, eds. Caring for Muslim patients, 2nd ed. Oxford: Radcliffe, 2007 (in press)
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Scottish Nutrition and Diet Resource Initiative. South Asian balance of good health (also available in Urdu, Hindi, and Punjabi). Order from www.caledonian.ac.uk/sndri/pdf/OtherHPform.pdf
This is part of a series of occasional articles on common problems in primary care. The BMJ welcomes contributions from general practitioners to the series
Thanks to Eiad Afaris, Domhnall Macauley, Chris Burton, Sangeeta Dhami, Brian McKinstry, Hilary Pinnock, Iftikhar Saraf, and Yasser Shehata for their helpful comments on earlier drafts of this article.
Contributors: AS conceived this article, and he contributed to and edited drafts written by SW. AS is guarantor.
Competing interests: SW and AS are grant holders on a randomised controlled trial of diabetes prevention in South Asians (NPRI/MRC R39913).
Provenance and peer review: Not commissioned; externally peer reviewed.