Fasting for People with Diabetes

Interview with Dr Noble Zachariah on Times Kuwait news paper

Would you please discuss the risks of fasting for Muslims with diabetes?

It is well known that fasting increases the risk of complications in people living with diabetes. The main complications that occur during fasting are:
Hypoglycemia (low blood sugar) which occurs 7 times more than at other times. It is considered mild when a person’s blood sugar is between 2.8mmol/l (50mg/dl) and 3.9mmol/l( 70mg/dl). The person may feel intense hunger, sweating, palpitation, trembling and become uncomfortable. Hypoglycemia is severe if the blood sugar falls below 2.8mmol. Confusion, loss of memory, transient paralysis, strokes, heart attacks, fits, loss of consciousness and even death may occur with profound hypoglycemia.

A condition called Hypoglycemia Unawareness can occur in some people where the classical symptoms do not occur, instead the person may have difficulty in concentration, thinking and speech may become slow and there may be a lack of co-ordination. The person and the people around may attribute these symptoms to some other condition and may not take immediate corrective measures to avoid serious complications, which can be life threatening.
Hypoglycemia may occur if the food intake is not adequate for the medicines used. It is more common with some long acting oral medicines or Insulin. The effect of the medicine to lower blood sugar lasts long and is not balanced by the glucose generated in the body during fasting. Often the dose of medicine and/ or the type of medicine may have to be modified while fasting to avoid hypoglycemia.

Hyperglycemia (high blood sugar) may occur 5 times more during fasting. This may be from over eating during non fasting hours, decreasing the use of oral medicines and insulin or defensive eating to avoid hypoglycemia by people who have experienced uncomfortable hypoglycemic episodes.

Diabetic ketoacidosis is a life threatening complication which can occur in people with Insulin deficient diabetes (Type 1 or late stages of Type 2). Most authorities discourage such people from fasting.
Dehydrationcan occur during fasting especially during summer months and in people working outdoors. The risk of thrombosis (blood clotting) is more in such people and worsens if hypoglycemia is also present.

Are the effects worsened if the person has poor control over his diabetes?

Diabetes can be controlled in all people with the proper knowledge, lifestyle management, stress relief and medication where required. If a person has poor diabetes control it is because one or more of these are ignored or are inappropriate. It is to be expected that complications can be more in such people with low awareness, motivation or inadequate guidance. Therefore it is highly recommended that people with diabetes who intent to fast should meet their healthcare provider to obtain good diabetes control and acquire appropriate knowledge to avoid complications as well as learn immediate corrective measures if a complication should occur.

Are there different risks for different groups of people with diabetes who fast?

The expert committee consisting of healthcare providers, clergy and people living with diabetes have accepted these groups depending on the risk for complications.

Very high risk

Severe hypoglycemia within the last 3 months prior to Ramadan
Patient with a history of recurrent hypoglycemia
Patients with hypoglycemia unawareness
Patients with sustained poor blood sugar control
Ketoacidosis within the last 3 months prior to Ramadan
Type 1 diabetes
Acute illness
Hyperosmolar hyperglycemic coma within the previous 3 months
Patients who perform intense physical labor
Pregnancy
Patients on chronic dialysis

High risk

Patients with moderate hyperglycemia (average blood glucose between 150 and 300 mg/dl, HbA1C 7.5–9.0%)
Patients with renal insuf?ciency
Patients with advanced macrovascular complications like heart disease
People living alone that are treated with insulin or sulfonylureas
Patients living alone
Patients with co-morbid conditions that present additional risk factors
Old age with ill health
On drugs that may affect mental alertness.

Moderate risk

Well controlled patients treated with short-acting oral medicines such as repaglinide Or nateglinide

Low risk

Well-controlled patients treated with diet alone, metformin, or a thiazolidinedione who are otherwise healthy.
Those who are controlled on newer categories of medicines incretins or SGLT2 inhibitors alone may be added to low risk or moderate risk groups.
The recommendation is that people belonging to the very high risk and the high risk group should not fast where as those belonging to the moderate and low risk groups can fast taking appropriate care to avoid complications.

What precautions can diabetic patients take when fasting?

People living with diabetes who want to fast should plan well.They and their care givers should meet their doctor and healthcare team and discuss all the aspects like food, activity, exercise and medication as these require some modification. Also, they and their care givers should be able to detect complications especially hypoglycemia and learn to take immediate corrective measures to avoid serious harm. This should be done well ahead of Ramadan preferably and also ensure that their blood sugar is well controlled before the start of Ramadan.
They should also monitor their blood sugars frequently during fasting using an accurate glucometer.

In what situation is fasting completely ill advised for people with diabetes?

Those in the Very high risk and High risk groups are advised not to fast.Anyone fasting should break the fast immediately if blood sugar falls below 3.3 mmol/l( 60mg/dl). Break the fast if the blood sugar falls below 3.9 mmol/l (70mg/dl) within a few hours of fasting. If blood sugar goes above16.7 mmol/l (300mg/dl), one should break the fast to seek treatment. People should not fast if they are sick and should break it if they become sick after beginning of fasting.

What are the changes to their diet and eating pattern would you encourage people living with diabetes to make?

The Holy month of Ramadan is a time when family members are closer to one another and do many activities together like praying, fasting, breaking the fast and eating together. Therefore, it would be better if the whole family would share the same food. The food should be wholesome and rich in micronutrients like vitamins, minerals, antioxidants, rich in fiber and not just empty calories as present in ‘Junk foods’. Unpolished whole grain foods instead of refined powders, complex carbohydrates as pulses, chick peas, leafy vegetables and others that are above the ground. Also, food items such as fish, chicken, turkey with skin removed, lean meat devoid of fat and low fat dairy products have their place.
We derive our energy from the macronutrients consisting of Carbohydrates, Proteins and Fats & Oils. The Calorie value of fats and oils is more than double that of Carbohydrates and Proteins and therefore the importance of restricting fats and oils in those who require losing weight or have co-existing lipid abnormalities. In planning a meal 3 parameters – Calorie, Glycemic Index ( GI) and Glycemic Load ( GL) are important. GI is the index of blood sugar elevation by the food compared to that by Glucose (Reference Food). This diagram illustrates why GI is important in the meal planning for people with diabetes.

The blood sugar is elevated to a higher level by high GI food than by low GI food. When the blood sugar is elevated the body takes corrective measures and brings it down to even lower than normal levels and may lead to hypoglycemia.
The sugar from low GI foods is slowly absorbed and does not reach a high level. The blood glucose remains closer to the normal level for longer period and the risk of hypoglycemia is less. This is the kind of food that one should eat at the pre-dawn (Suhoor) meal.

Many people think that food that tastes sweet are harmful and what does not taste sweet is alright. This is a misconception as foods like white bread, cornflakes, French fries etc which are not sweet have higher GI than the table sugar (Sucrose) that we use. Another important factor one should consider is the Glycemic Load (GL). This is GI multiplied by the amount of Carbohydrate present in a serving of the food. It is not necessary for high GI food to be high GL. For example watermelon is a high GI food but the GL is low. This is the kind of food one should eat at the time of breaking the fast (Fathoor). Nearing the fast breaking time one tends to get hypoglycemic and dehydrated. Watermelon would bring up the blood sugar very fast because it is high GI but the elevated sugar is not prolonged as GL is low. There are websites that offer information regarding GI and GL of foods. If not,your health care provider would be able to help.
Many people are misled by advertisements of commercial ‘ diabetic food’. This has no advantage over eating wholesome food following the principles mentioned above. These foods benefit others more than the consumers.

What is a healthy exercise program for people with diabetes?

Physical activity and exercise should be continued in Ramadan but the time should be adjusted to non fasting hours. People should not be involved in strenuous physical activity near the fast breaking time as the risk of hypoglycemia and dehydration are more. It is better to exercise 2hours after the evening meal or before the pre dawn meal. One should remember to take plenty of fluids while exercising. Small snacks can be allowed if the blood sugar is well controlled. They should not exercise during day time in the hot weather as insensible loss of water can lead to dehydration. Also people with uncontrolled diabetes may become dehydrated easily as they urinate more and lose more body water.
Those above the age of 40 or had diabetes for more than 10 years should be examined by a doctor before they start an exercise program for the first time. Moderate exercise which elevates their heart rate to 60-70% of their maximal heart rate determined by age is the optimum exercise and should be at least 150 minutes per week.

How should people with diabetes manage their oral medicines / insulin during fasting?

This has to be individualized.The treating doctor will advise which medicines to use and when along with giving information regarding diet and activity.

The treating doctor may advise to avoid taking long acting sulfonyl urea type of medicine or intermediate acting Insulin before the pre-dawn meal (Suhoor) as the risk of hypoglycemia is higher with these medicines. Oral medicines may have to be changed or the existing medicine’s dose may have to be changed and this can only be decided by the treating doctor. In this regard it is very important to discuss with your primary treating doctor if one is planning to fast. Do not depend on any other person’s advice in this regard.

What eating habits during Ramadan could lead people to develop diabetes or other related conditions?

There is a tendency for many people to eat high calorie high GI food like sweets and other calorie rich food during the numerous parties and family gatherings. This may be a triggering factor and precipitate diabetes in people who are at risk like those with pre-diabetes or have family history of diabetes. Some people gain weight and develop the complications associated with the same.

What measures should those individuals predisposed to diabetes take to stay healthy, please advice?

Studies have shown that diabetes can be prevented in the majority of people at risk of diabetes. Maintaining the ideal body weight, eating a low GI wholesome food, exercising to keep oneself fit and healthy, avoiding smoking and managing stress well are all very helpful in preventing diabetes.

Can fasting for people with diabetes be a beneficial experience if patients take the right precautions?

Most doctors advise people living with diabetes not to fast as the complications are many times more in those who fast. Fasting being one of the five pillars of Islam, many people with diabetes fast in spite of the dangers and the exemption granted to them by the religion. Members of other religions also may fast due to social or other reasons. Those in the moderate or low risk group may fast taking all the precautions mentioned before and derive all the benefits associated with fasting. Those in the very high risk and high risk group should not fast. If they want to fast against medical advice, a care giver well trained in handling the complications of fasting should be constantly with the person and frequently monitor blood sugar and other parameters during the fasting hours and should take all the precautions. If any of the criteria for breaking the fast is present, the care giver should take charge and break the fast irrespective of the person’s consent.

Can you please name a few resources that offer beneficial information to people with diabetes?

There are about 400million people living with diabetes in the world as per the International Diabetes Federation’s estimate. There are a large number of websites that cater to such a large segment of the population. Many of them provide valuable information. It is important to know that some of them are commercial sites and their information may have some commercial interest. International Diabetes Federation American Diabetes Association, National Diabetes Education Program of the US Government have useful information devoid of much commercialism. Closer home, Indian Doctors Forum brought out a health guide devoted to diabetes 3 years ago and most aspects of diabetes are dealt with in it. 

What health advice do you have for regular people who are fasting in the summer, and what precautions can they take to avoid diseases or health issues?

All the advice given to people with diabetes regarding the diet, activity and exercise are applicable also to those who do not have diabetes.

I wish all the Blessings of Ramadan, good health and happiness.