Diabetes & Ramadan
The Experts Weigh In
Here's What You Need To Know ...

I don't need to tell you that fasting during the long + hot days of summer can be tough for any of us, no matter how healthy or fit we are.  But for the nearly 100,000 Canadian Muslims suffering from Diabetes the physical challenges of Ramadan can be even more taxing with potential implications on both short-term wellbeing and long-term health. The long hours of absolute fasting during the daytime and eating at night can increase the risk of dehydration, hypoglycemia and hyperglycemia for individuals with diabetes.  

Until now, there hasn't been much expert-level guidance on how diabetic patients can approach fasting in a healthy & informed manner.  Fortunately, a new Canadian position statement authored by "Diabetes Canada" is now available. Developed by an expert faculty, it is the first ever such paper exploring the issues surround fasting in Ramadan with diabetes, and provides guidance to health-care providers to assist Canadian Muslims living with diabetes during Ramadan.

Dr Tayyab Khan is one of the co-authors of this important paper. He's an Endocrinologist with a special focus on Diabetes with a practice in Oakville.  I had the opportunity to speak with him to ask him about some important and practical issues for Muslims with diabetes who choose to fast.  



1. Generally speaking, what would you say are the major challenges that someone with diabetes needs to consider when fasting, especially with the fasts being so long in the summer months?

Dr Khan - There are a number of challenges for those with diabetes who fast during Ramadan. The foremost among these is the risk of hypoglycaemia, or having an episode where blood glucose drops to less than 4mmol/L. In this case, patients can have symptoms like tremors, racing heart (palpitations), sweating. If prolonged, or in patients in whom this happens frequently, may not have these symptoms but rather have more severe symptoms of confusion, loss of consciousness, or seizures. Patients with diabetes are at a 5-7 times higher risk of having these episodes when fasting compared to non fasting months. This risk is higher for those who take medications like insulin. Conversely, is the risk of hyperglycemia, or having high sugars. This could be due to poor control of diabetes prior to Ramadan, or the use of meals high in carbohydrate content at suhoor or iftar, or not taking ones medications regularly. Patients with diabetes are at 3-5 times higher risk of having hyperglycemia when fasting during Ramadan compared to the non fasting months. Related to this risk is one of dehydration, which is especially important when fasting hours can be 17-18 hours long during the summer months. Finally patients with diabetes are also at a higher risk of developing blood clots when fasting. This is at least partly related to dehydration, but other mechanisms play a role as well. The main risk factors for having any of these complications include poor control of diabetes, use of medications that may increase the risk of these complications, and a personal history of having these complications. For the vast majority of those with diabetes, these can be avoided by simple steps, including a consultation with one's healthcare provider prior to Ramadan, changing medications, if possible to avoid these complications,  and maintaining a balanced diet and adequate fluid intake so as to avoid these complications.

2. Are there any types of foods that you recommend a diabetic patient eat (or avoid) at Suhoor or Iftaar?  

Dr Khan - We suggest having a balanced diet with multiple food sources. These principles are not specific to Ramadan, but should be used outside of Ramadan as well. We recommend having one serving of protein, chicken or fish preferred over red meat, one starch source, e.g. one average sized bread (roti) or one cup of cooked rice and not both, lots of salad, a cup of milk and any fruit that you may like. In Ramadan, the fruit source can be replaced by 2-3 small sized dates. We recommend avoiding simple carbohydrates, e.g. fruit juices, regular pop drinks which not only cause a sudden increase in blood sugar, but have potential to lead to a decrease thereafter. Given the long fasting hours and the risk of dehydration, we also recommend drinking lots of water to remain hydrated.

3. The most common form of diabetes is Type 2 (non-insulin-dependent) diabetes, and there are now so many different classes of medications that these patients might use to help regulate their blood sugars.  Are there any types of medications in particular that you would recommend increased caution using during Ramadan (or maybe even advise that people avoid while fasting?)

Dr Khan - While most medications do not need adjustment. Among the ones that do need some adjustment include insulin and medications caused secretagogues, e.g. gliclazide, glyburide etc, which cause the body to produce more insulin. With either of these is a risk of causing hypoglycemia, or an episode when blood sugar goes low. In well controlled patients, the dosage of these medications should be adjusted prior to Ramadan to avoid these episodes. The other two classes that should be used with caution include  Sodium-glucose co-transporter-2 (SGLT2) inhibitors and Glucagon -like peptide receptor-1 agonists (GLP-1 agonists). These medications are not only effective against controlling blood glucose, but have also been shown to be protective for the heart as well. However, they can cause dehydration, and should be used with caution in those who intend to fast.

4. Although Type 1 (insulin-dependent) diabetes is less common, is it fair to say that these patients might need be even more careful when fasting? (since extreme changes in blood sugars could potentially lead to life-threatening complications).  What are the main things that patients with Type I diabetes should consider as they head into Ramadan?

Dr Khan - It is indeed fair to say that these patients need to be even more careful. This is because these patients require insulin with each meal. While excess of insulin can lead to hypoglycemia, while deficit can lead to hyperglycemia and a condition called diabetic ketoacidosis, when the body starts to use fat as fuel source rather than glucose. Either of these conditions can be medical emergencies. Therefore, it is generally recommended that these patients seek medical attention prior to Ramadan. Most diabetes experts would recommend against fasting for individuals with type 1 diabetes. However, we know that about 40% of them still fast during Ramadan. In order to do so safely, it is important to have a pre-Ramadan assessment where their healthcare provider can adjust their insulin dose, and inform them of the need for monitoring blood glucose frequently, often up to five times per day to ensure glucose is checked and kept within the normal range. Despite this, in case patients experience hypoglycemia (Glucose <4), or significant hyperglycemia (Glucose >16.6), it is very important to break the fast to correct these conditions.

5. Fasting is considered an important act of worship and described as one of the pillars of faith, however Islam does offer exceptions to individuals unable to fast due to illness or health risk.  What recommendations do you have to diabetics who are uncertain whether or not to fast during this month?

Dr Khan - As mentioned, it is paramount to seek medical as well as religious advice in this regard. We recommend having a pre Ramadan appointment with your healthcare practitioner 6-8 weeks prior to Ramadan, in which an assessment can be made regarding glucose control, and an informed decision can be made regarding patients' ability to fast during Ramadan. A large majority of patients who are well controlled and have not experienced complications mentioned above may be able to fast without any changes to their medications. However, for those who have had the complications mentioned above, or have had recent diabetes related complications, e.g. a heart attack, stroke etc, it may be advisable to fast during Ramadan and this decision should be made in concert with the healthcare provider and the Imam.

Thanks for taking time out of your busy schedule to answer these questions for us today.  And Thanks again for your amazing work and service in this field and for your part in putting together this paper.  There’s such a huge need for health education and promotion in our community, and this is such an important topic that affects so many of our brothers and sisters (not to mention their families). May you be rewarded for all of your efforts!