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Volume 24, Number 1 - March 2021

Ramadan: a practical approach

for diabetes educators
Feature ArticleLiving With DiabetesTeaching Tips

BY Michelle Robins

nutrition person-centred care resources

Introduction
The hol month of Ramadan falls between Monda 12 April and Tuesda 11 Ma in 2021.
The Islamic Council of Victoria highlights that although Islam is a single religion, Muslim
people are not a single homogenous group, with more than 500,000 Muslims living in
Australian from over 70 countries around the world. Fasting during Ramadan is one of the
Five Pillars of Islam and is obligator for all health Muslims who have reached pubert.

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Followers are required to refrain from eating or drinking between dawn and sunset,
including taking oral medications and smoking. People with a chronic disease, those who
are unwell, the elderl and women who are pregnant or breastfeeding are exempt from
fasting, however man people with diabetes activel choose to fast.

In order to provide client-centred care, it is important for diabetes educators to understand

the importance of fasting and the changes in diabetes management required to assist
clients to safel fast. Depending on the ear and geographic location, fasting can last
between 11 and 19 hours.

Guidelines for diabetes management during Ramadan

everal clinical guidelines have been developed to support health care professionals
working with people with diabetes who choose to fast during Ramadan. 1-2 The
International Diabetes Federation in collaboration with the Diabetes and Ramadan
International Alliance (IDF-DAR) released a comprehensive document in 2016 titled
Diabetes and Ramadan: Practical Guidelines and more recentl a free on-line short course
on the IDF website. 1 This publication was ground breaking at the time, with its focus on
risk strati�cation and clinical recommendations.

Using the IDF-DAR publication, the Australian Diabetes ociet provides three practical
resources: one for people with diabetes, one for Imams (Islamic leaders) and one for health
care professionals (HCPs). 3-5 Each brochure incorporates the IDF-DAR recommendations
of risk strati�cation. This includes a tra�c light approach whereb speci�c risks are
highlighted to identif individuals with diabetes who are advised not to fast (red), those who
ma require additional support (amber) and those who could fast with minimal intervention
(green) – see Figure 1.

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The recentl revised RACGP Management of tpe 2 diabetes: A Handbook for general
practice, takes a slightl di�erent approach. 6 The American Diabetes Association and the
European Association for the tud of Diabetes consensus report on the Management of
Hperglcaemia in Tpe 2 Diabetes, 2018, released a revised version last ear focusing
solel on the decision ccle of clinical care, education, nutrition and modi�cations with
respect to all glucose lowering medicines (GLM) during Ramadan. 2 With its two goals of
care being to manage smptoms and prevent complications, this publication clearl
outlines how each class of GLM could be used, modi�ed or ceased during Ramadan.

Regardless of which set of clinical guidelines are used, assessment and structured
education is required. The time preceding Ramadan is an ideal opportunit for diabetes
educators to educate and work with their clients to plan for this important event. The most
important thing to do as diabetes educators is to simpl ask if our clients are planning to
fast for Ramadan. It is also essential that we support individual choice and can provide
management strategies to assist in fasting and that we are aware of available resources
and undertake the upskilling required to support our clients. Being open and receptive is
extremel important as seen in a qualitative stud conducted in Melbourne in 2014 which
found that women with Gestational Diabetes (including those requiring insulin) often chose
to hide their fasting from HCPs. 7

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In the UK a whole sstems approach known as ‘A afer Ramadan’ was undertaken several
ears ago. 8 The three arms to this intervention focused on raising communit awareness
of the impact of Ramadan and diabetes including the production of a slide set designed to
be delivered b local communit leaders and HCPs to reach a wide range of audiences.
The second element was the development and deliver of HCP training module. The �nal
component was a three-hour group structured self-management education program for
people with diabetes promoting informed choices around fasting and supported with
interactive resources. This paper ma be useful for health professionals who are looking to
do something similar within their own facilit or communit.

Managing risks – the importance of assessment and education

Fasting during Ramadan increases the risks for hperglcaemia, Diabetic Ketoacidosis,
dehdration and thrombosis. 1 It should be noted that up to 30% of Muslims fast
intermittentl throughout the ear. 1

However, the main concern for diabetes management during Ramadan is hpoglcaemia
and individuals receiving pre-Ramadan education experience less hpoglcaemia. 9 There
are a number of factors, in addition to the propensit for hpoglcaemia, to consider for risk
strati�cation including: 10

• Tpe of diabetes
• Current diabetes treatment
• Degree of diabetes management
• Competence at self-management
• Previous Ramadan experience
• Presence of diabetes-related complications
• Presence of other co-morbidities
• Ongoing or recent intercurrent illness
• Degree of frailt
• Level of cognition
• Polpharmac burden
• Occupation
• ocial circumstances

In a stud conducted over 12 clinics in four Middle Eastern countries, 515 people with tpe
2 diabetes received individualised education prior to Ramadan, self-management activities
such as increased frequenc of blood glucose monitoring, changes to diet and exercise
were more likel to be undertaken compared to 259 clients who received usual care. 11
Eight percent of participants increased the frequenc of their blood glucose monitoring

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during Ramadan. Both cohorts had similar smptom reporting of mild hpoglcaemia and
hperglcaemia, though a higher rate of moderate hpoglcaemia was seen in the
intervention group. Participants receiving pre-Ramadan education were less likel to
experience severe hpoglcaemia requiring medical assistance or hospitalisation for an
other reason. Of note the intervention group lost on average nearl 3kg during the month
of Ramadan compared to 0.5kg weight loss for the control group.

All clinical guidelines focus on the importance of pre-Ramadan assessment, as a number of

ke diabetes self-management issues will require review and possibl revision to meet the
two goals of care: management of smptoms and prevention of complications. Assessment
and education should include:

• elf-monitoring of blood glucose, not just the frequenc which ma be increased, but
also that it is allowed to be undertaken during the da
• Dietitian review and education that focuses on how to break the fast (maximum of 3
dates), carbohdrate intake, minimising foods high in re�ned sugar and saturated fats,
portion control, increased �uid intake especiall with the pre-dawn meal of uhoor, and
the tpes of drinks consumed (avoiding ca�einated and sweetened drinks)
• Phsical activit including during Taraweeh at night, which can be a ver active form of
praer
• moking invalidates a fast and is an ideal opportunit to promote smoking cessation
• Review of glucose lowering medicines, with particular focus on insulin and sulfonlureas,
but also changing regimens and administration time to �t within non-fasting periods
• Review of other medicines such as diuretics
• When to break the fast in terms of low or raised blood glucose levels
• ick da management plans
• Eid-ul-Fitr three-da festival post-Ramadan

People with diabetes considered at ver high and high risk who wish to fast, should attempt
a trial fast prior to Ramadan, especiall if changes have been made to their medicine
regimen to support fasting. Part of a person’s Diabetes Ramadan Plan ma consist of
having the occasional ‘da o�’ from fasting, rather than undertake the continuous 30-da
period, which could be made up later in the ear, however there appears to be some
variation in opinion as to whether and how this can be undertaken among di�erent
communities. As we move into more hours of dalight in Australia each ear during
Ramadan (commencing 2nd April 2022 and 22nd March 2023), this ma pose additional
challenges to people with complex medical conditions. If fasting das could not be
undertaken outside Ramadan, a redemption fee of ‘�dah’ can be made. Diabetes
complications screening should be completed prior to Ramadan or be booked in directl
after Ramadan, as Muslims with diabetes often are uncomfortable to undertake patholog
testing at this time. ick da management and sick da plans should also be updated,

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especiall for those clients taking sodium-glucose cotransporter-2 inhibitors. 12

Technologies such as continuous glucose and �ash glucose monitoring, which have
illustrated signi�cant glucose variabilit in those taking part in Ramadan ma assist people
with diabetes to reduce variabilit and hpoglcaemia during fasting. 13

Medication adjustments during Ramadan

Current guidelines recommend that the decision to start an new GLMs should be
implemented and assessed before Ramadan and that communication be open to review
and adjust GLMs especiall if hpoglcaemia or medicine intolerabilit occurs during
fasting. 2

Recommended changes to common non-insulin glucose lowering medicines 2, 6, 12

Prior to Ramadan During Ramadan

No change in total dail dose
Once a da – usual dose at Iftaar (evening) meal
Metformin
Twice a da – usual dose at Iftaar and uhoor
Three times a da – combine lunch dose with Iftaar,

ulfonlurea Consider either substituting, stopping or reducing dose

No change in dose – should be well established prior to Ramadan

GLT2i Ensure adequate hdration, take with Iftaar

Do not commence immediatel prior or during Ramadan

No change in dose – should be well established prior to Ramadan (8 weeks)

GLP1RA
Reduce or stop if nausea or vomiting occurs

DPP4i No change in total dail dose

Recommended changes to insulin for people with tpe 2 diabetes 2, 14

Insulin therap Dosing advice

Once dail dosing administered in evening, ma need dose reduction 15-30%
Basal insulin
Twice dail dosing – reduce morning dose at uhoor b 25-50%

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Omit lunchtime dose

Bolus insulin Ma require increased dose with Iftaar

Reduce morning dose at uhoor b 25-50%

Higher risk for hpoglcaemia on bd dosing

Usuall take normal dose with Iftaar
Premixed insulin
Reduce morning dose at uhoor b 25-50%
Ma consider switching to basal insulin for Ramadan

Currentl no recommendation

Co-formulated insulin Likel no change to dail dosing taken with Iftaar

BD dosing – consider reducing dose at uhoor b 25-50%

Ibrahim et al (2020) recommend using a basal insulin known to have a lower risk of
hpoglcaemia such as U300 glargine. 2 In a trial of 263 adults in �ve countries with tpe 2
diabetes, Rzodeg70/30® reduced severe and nocturnal hpoglcaemic events in
participants fasting during Ramdan compared to Novomix30®.13 However the longer half-
life of both Toujeo® (U300 glargine) and Rzodeg70/30® must be considered and changes
Conclusion
to dosing incorporated two to three das prior to the commencement of Ramadan. Ibrahim
et al (2020) has also produced an algorithm for premixed insulin titration during Ramadan
Ever
for ear with
people mantpe
Muslims with diabetes
2 diabetes, below. will fast during Ramadan. Unfortunatel some
HCPs ma fail to appreciate the signi�cance of this time and the religious and cultural
sensitivities involved.
Fasting/pre-meal This can mean
blood glucose that our clients
Recommended action ma not be telling us the truth about
fasting and ma struggle to self-manage their
Break the fastdiabetes without professional input,
impacting
>16.6mmol/Lon both their qualit of life and safet. Asking the question, starting the
Increase dail insulin dose b 20%
conversation, increasing our awareness of Ramadan and becoming familiar with the
consensus
>10mmol/L guidelines to better manage diabetes
Increase aredose
insulin dail some of the most important things
b 10%
we can o�er to our Muslim clients.
5.5 – 10.0mmol/L No change
Break the fast
<3.9mmol/L
Reduce insulin dail dose b 20%
Acknowledgements
Break the fast
<2.8mmol/L
Resources: top insulin – OR reduce insulin dail dose b 30-40%

Australian Diabetes ociet

• D i a b e t e s d u r i n g Ra m a d a n : P a t i e n t G u i d e –
PDF https://diabetessociet.com.au/documents
/DARPatientLea�et-Cop.pdf
• Ra m a d a n a n d D i a b e t e s : G u i d a n c e  h e e t f o r
I m a m – PDF https://diabetessociet.com.au

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/documents/DARImamlea�et-Cop.pdf
• M a n a g e m e n t o f D i a b e t e s D u r i n g Ra m a d a n :
Q u i c k Re f e r e n c e G u i d e f o r H e a l t h
P r o f e s s i o n a l s – PDF
https://diabetessociet.com.au/documents
/DARHCPLea�et-Cop.pdf
Diabetes NW & ACT (2019)

• Managing diabetes during Ramadan Ma 2019

https://diabetesnsw.com.au/about-us/blog
/managing-diabetes-during-ramadan/
Diabetes UK (2017)

• Fasting and managing our diabetes during

Ramadan: English https://www.diabetes.org.uk
/resources-s3/2017-09
/1118A_Ramadan%20Factsheet_Update_April2017_amended.pdf
• Fasting and managing our diabetes during
Ramadan: Arabic https://www.diabetes.org.uk
/resources-s3/2017-09
/Ramadan%20Factsheet_to%20send%20-%20Arabic.pdf
• Fasting and managing our diabetes during
Ramadan: Bengali https://www.diabetes.org.uk
/resources-s3/2017-09
/Ramadan%20Factsheet_to%20send%20-%20Bengali.pdf
Fasting and managing our diabetes during
Ramadan: Urdu https://www.diabetes.org.uk
/resources-s3/2017-09
/Ramadan%20Factsheet_to%20send%20-%20Urdu.pdf

References
1. The International Diabetes Federation in collaboration with the Diabetes and Ramadan
International Alliance (IDF-DAR) released a comprehensive document in 2016 titled
Diabetes and Ramadan: Practical Guidelines April 2016.

2. Ibrahim. M, Davies. M, Ahmad. E et al Recommendations for management of diabetes

during Ramadan: update 2020, appling the principles of the ADA/EAD consensus. BMJ
Open Diab Res Care 2020;8:e001248.Â

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ADE | Ramadan: a practical approach for diabetes educators https://ade.adea.com.au/ramadan-a-practical-approach-for-diabetes-educ...

3. Australian Diabetes ociet Diabetes during Ramadan: Patient Guide

https://diabetessociet.com.au/documents/DARPatientLea�et-Cop.pdf Â

4. Australian Diabetes ociet Ramadan and Diabetes: Guidance heet for Imam
https://diabetessociet.com.au/documents/DARImamlea�et-Cop.pdf Â

5. Australian Diabetes ociet Management of Diabetes During Ramadan: Quick

Reference Guide for Health Professionals
https://diabetessociet.com.au/documents/DARHCPLea�et-Cop.pdf Â

6. Roal Australian College of General Practitioners Management of tpe 2 diabetes: A

handbook for general practice. East Melbourne Jul 2020.Â

7. Ritchie. A, Robins. M, Hutchinson. A, Varadarajan. , Howat. P Qualitative stud:

Perceptions of women with previous gestational diabetes during Ramadan pertaining to
fasting. Presented at the ADIP Conference 2015, Gold Coast.Â

8. Dal. H, Brne. J, Martin-tace. L et al âA afer Ramadanâ: developing an integrated

approach to support safer fasting and feasting for people with tpe 2 diabetes. Practical
Diabetes 2014;31:292-7.Â

9. Yorke. E, Atiase. Y Impact of structured education on glucose control and

hpoglcaemia in tpe-2 diabetes: a sstematic review of randomized controlled trials
Ghana Med J 2018;52:41-60.Â

10. Ahmed. , Chowdhur. T, Hussain.  et al Ramadan and Diabetes: A Narrative Review

and Practice Update Diabetes The 2020 11:2477-2520.Â

11. McEwan. L, Ibrahim. M, Ali. N et al Impact on an individualized tpe 2 diabetes

education program on clinical outcomes during Ramadan BMJ Open Diab Res Care
2015;3:3000111.

12. Grajower. M, Horne. B Clinical management of intermittent fasting in patients with

diabetes mellitus Nutrients 2019;11:E873.

13. Lessan. N, Hannoun. Z, Hasan. H et al Glucose excursion and glcaemic control during
Ramadan fasting in diabetic patients: insights from continuous glucose monitoring (CGM)
Diabetes Metab 2015;41:28-36. Â

14. Hassanein. M Echta. A, Malek. R et al E�cac and safet of insulin degludec/insulin

aspart in adults with tpe 2 diabetes fasting during Ramadan. Presented at the IDF
Congress 2017, Abu Dhabi.

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