Achieving Best Practice

Diabetes and Ramadan: how to achieve a

safer fast for Muslims with diabetes
Mohamed M Hassanein

Abstract

R
amadan is a holy month for all Muslims, when they
fast from dawn to sunset. Although the Qur’an
exempts the sick from fasting, many Muslims with
diabetes passionately fast despite their medical condi-
tion. The main risks encountered during fasting include
worsening of glycaemic control or hypoglycaemia. A bet-
ter understanding about fasting Ramadan and its risks is
an important step for all healthcare professionals man-
aging Muslim people with diabetes. This entails improv-
ing patient education as well as tailoring the treatment Mohamed M Hassanein
to meet the needs of this group of people with diabetes
to minimise the possible risks.
Br J Diabetes Vasc Dis 2010;10:246-250.

Key words: diabetes, fasting, hypoglycaemia, Ramadan Abbreviations and acronyms

ADA American Diabetes Association

Introduction
EPIDIAR Epidemiology of Diabetes and Ramadan
Fasting Ramadan is one of the five main pillars of Islam and is
GLP-1 glucagon-like peptide-1
passionately practised by millions of Muslims across the world. HbA1C glycated haemoglobin A1C
In 2010 Ramadan started on 11 August. The lunar calendar is HCP healthcare professional
about 11 days shorter than the Christian calendar. Hence, NICE National Institute for Health and Clinical Excellence
Ramadan is expected to start during the summer time for the UAE United Arab Emirates
next 15 years, when the average daily fasting hours in the UK
will be > 16 hours. The Qur’an says:

But whoever of you is ill, or on a journey, [shall fast instead for the
same] number of other days; and [in such cases] it is incumbent
people enjoy the spiritual atmosphere during that month and
upon those who can afford it to make sacrifice by feeding a needy consequently, many of those who cannot fast feel they miss a
person (Sura 2: Verse: 184). great deal. A study of over 12,243 persons with diabetes
across different Muslim countries indicated that > 40% of
patients with type 1 and > 78% of patients with type 2 diabe-
Consequently, many people are exempt from fasting includ-
tes fast > 15 days during Ramadan.1 Hence, it is important
ing those who are ill, travelling, pregnant women, during breast-
for HCPs to be aware of the risks that may be associated with
feeding or women during their menses. Fasting lasts from dawn
fasting during Ramadan. The metabolic impacts of fasting for
to sunset, during which period any fasting Muslim should not
people with diabetes are multiple. They range from the risk of
eat or drink. This includes taking any oral medication. Many
increased frequency of hypoglycaemia, postprandial hypergly-
caemia with or without diabetic ketoacidosis, dehydration and
thrombosis.
Correspondence to: Dr Mohamed M Hassanein
Renal and Diabetes Centre, Glan Clwyd Hospital, Rhyl LL18 5U,
Dietary habits during Ramadan
Wales, UK.
Tel: +44 (0)1745 445709; Fax: +44 (0)1745 534354
During Ramadan many people have a meal after sunset,
E-mail: Mohamed.Hassanein@wales.nhs.uk referred to as Iftar (breaking of the fast), and a smaller meal
before dawn referred to as Suhur (pre-dawn). In the next few

© The Author(s), 2010. Reprints and permissions: http://www.sagepub.co.uk/journalsPermissions.nav

246 5 . september/october 2010
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years, due to the long fasting hours, there is a strong possibility
that the Iftar meal might become too large. The general atmo-
sphere of the month is usually of celebration and hence fasting
during the day is often followed with a feast of plenty of food
items in the evening. The consumption of many sweets is much
higher during Ramadan. Indeed, the dietary habit of many
Muslims is to break their fast with some dates or a sugary
drink.
Risks associated with fasting Ramadan and diabetes
The exact medical impact of fasting among people with dia-
betes is not well studied. However, both the religious and
medical advice are clear that some people with diabetes are
exempt from and should avoid fasting due to the risks to their
metabolic condition. To minimise the risks of fasting Ramadan,
the ADA published a consensus statement2 on the manage-
ment of diabetes during the month of Ramadan in 2005.
An up-to-date British recommendation would be a welcome
move by Diabetes UK.
The major metabolic risks associated with fasting in people
with diabetes are hypoglycaemia, hyperglycaemia and diabetic
ketoacidosis and dehydration and thrombosis.
Hypoglycaemia
There is an increasing awareness of the risk for hypoglycaemia
in people with diabetes. This risk is potentially higher during
fasting Ramadan. A study conducted in London in 2007 on
111 persons with type 2 diabetes treated with oral hypoglycae-
mic agents showed that the incidence of any hypoglycaemic
episode increased four-fold during Ramadan, compared with
before fasting.3 The risk of severe hypoglycemia (defined as
hospitalisation due to hypoglycaemia) in the EPIDIAR study1
increased during Ramadan fasting, in 2001, about five-fold in
patients with type 1 (from 3 to 14 events per 100 persons per
month) and ~7.5-fold in patients with type 2 diabetes (from
0.4 to 3 events per 100 persons per month).
Hyperglycaemia and diabetic ketoacidosis
Glycaemic control in patients with diabetes who fast during
Ramadan has been reported to deteriorate, improve or show
no change.4-9 In a study from London, there was no significant
change in HbA1C before and after Ramadan.3 Severe hyper­
glycaemia requiring hospitalisation increased five-fold during
Ramadan in patients with type 2 diabetes and in type 1 dia-
betes was approximately three-fold higher with or without
ketoacidosis.1
Dehydration and thrombosis
Dehydration is a theoretical risk among individuals who per-
form hard physical labour while fasting for long hours. The
decrease in endogenous anticoagulants, impaired fibrinolysis
and the increase in clotting factors noted in some patients with
diabetes could be a risk for thrombosis.10 Retinal vein occlusion
in people who fasted during Ramadan was increased in one
study.11 However, there was no increase in hospitalisations due
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Achieving Best Practice
to thrombotic cardiac or cerebral conditions during Ramadan in
the same group.3,11
The harmony between medical and religious advice
The Qur’an exempts the ill person from fasting. However, dia-
betes is a condition which varies in severity significantly from
one person to another. Hence, it is impossible to generalise
who should fast and who should not. Consequently, this has
been a controversial area lacking harmony between medical
and religious advice. However, a breakthrough recently occurred
following the decree of the Organisation of the Islamic
Conference at its 19th session held in the UAE in April 2009.12
The conference included eminent Muslim clerics and diabetes
experts who reviewed the medical evidence and the risk cate-
gories stated in the ADA 2005 consensus document.2 They
based their decisions, summarised in table 1,13 on the risk of
harm to the body. Risk of harm is prohibited in Islam as the
Qur’an says:
And let not your own hands throw you into destruction (Sura 2:
verse 195)
and
and do not destroy one another: for, behold, God is indeed a dispenser
of grace unto you (Sura 4: Verse 29).
It is importsant to note that despite the harmony between
religious and medical advice, many Muslim patients would
choose to fast during Ramadan.
Minimising the risks of fasting Ramadan and diabetes
Many Muslims with diabetes are very passionate about fasting
Ramadan and many HCPs find that they are unable to give
appropriate medical advice. This is often due to lack of knowl-
edge about Ramadan fasting. Indeed, to avoid confrontations
with the patient’s religious beliefs, some HCPs might agree to
reduce glycaemic control medication despite control being sub-
optimal. While it is crucial to respect a patient’s personal deci-
sion, it is essential that the medical advice provided by HCPs is
sound. Hence, an awareness campaign for HCPs as well as
community leaders is essential.
A pre-Ramadan diabetes assessment is recommended
so that patients can be made aware of individual risks and
recommended strategies to minimise these risks – or even
advised to refrain from full observance due to their current
health status.
Ramadan-related diabetes education for HCPs and
community leaders
Over the last few years, some regions across the UK have indi-
vidually started campaigns to raise the awareness of Ramadan
and diabetes. I have been privileged to help in many of these
initiatives. The efforts in these centres have varied and many
campaigns included local Imams and community leaders. The
aim in all centres was to provide a better understanding of
Ramadan and fasting for people with diabetes: including the
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Table 1.  Diabetes and fasting Ramadan: summary of recommendations
of the Organisation of the Islamic Conference13
Category 1: very high-risk group
• Severe hypoglycaemia within the last 3 months prior to
Ramadan
• Patients with a history of recurrent hypoglycaemia
• Patients with lack of hypoglycaemia awareness
• Patients with sustained poor glycaemic control
• Ketoacidosis within the last 3 months prior to Ramadan
• Type 1 diabetes
• Acute illness
• Hyperosmolar hyperglycaemic coma within the previous
3 months
• Patients who perform intense physical labour
• Pregnancy
• Patients on chronic dialysis
Category 2: high-risk group
• Patients with moderate hyperglycaemia blood glucose
levels of 10.0–16.5 mmol/L (180–300 mg/dL) or high HbA1C
(> 10%)
• Patients with renal insufficiency
• Patients with advanced macrovascular complications
• People living alone who are treated with insulin or
sulphonylureas
• Patients living alone with comorbid conditions that present
additional risk factors
• Old age with ill health
• Drugs that may affect cognitive state
The ruling for patients in categories 1 and 2 is that
they are prohibited from fasting to prevent harming
themselves based on the certainty or the predominance
of probability that harm will occur to the patients in
these two categories.
Category 3: moderate risk
• Well-controlled patients treated with short-acting insulin
secretagogues such as repaglinide or nateglinide
Category 4: low risk
• Well-controlled patients treated with diet alone, metformin,
or a thiazolidinedione, who are otherwise healthy
The ruling for patients in categories 3 and 4 is that they
should fast.
Obviously, the risk category for many people could be higher
or lower depending on many changes such as an acute illness,
pregnancy, a change in type of treatment, etc.
Key: HbA1C = glycated haemoglobin A1C
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religious background, the risks and the possible medical options
to achieve a better and safer outcome for those who wish to
fast and, indeed, for those who cannot fast during Ramadan.
Ramadan-focused diabetes education for people with
diabetes
The role of structured education is well established in the man-
agement of diabetes. This should be extended to Ramadan-
focused diabetes education as well as standard diabetes
education. As discussed previously, in Brent in London, follow-
ing raising awareness for HCPs, Ramadan-focused structured
education was offered to a group of 111 persons with type 2
diabetes.3 Those who undertook the Ramadan-focused diabe-
tes education programme (57 persons) had at baseline nine
hypoglycaemic events. However, at the end of Ramadan, their
hypoglycaemic events were only five, i.e. they managed to fast
during Ramadan and reduce the frequency of hypoglycaemia
compared with before Ramadan. The control group (54 per-
sons) who did not participate in the programme had a four-
fold increase in hypoglycaemic events – rising from nine events
at baseline to 36 events at the end of Ramadan. It is important
to note that this occurred while glycaemic control was main-
tained at the same level for 12 months. Furthermore, the
group who received structured education lost a small amount
of weight compared with an overall weight gain in the control
group.13
An education programme should include standard diabetes
education as well as Ramadan-related issues such as the pos-
sible risks of fasting for people with diabetes, the importance
of capillary blood glucose monitoring, when to stop the fast,
as well as meal planning and physical activity that takes into
account the prolonged fasting hours. The education session
should include advice on possible meal choices to avoid post-
prandial hyperglycaemia as well as avoiding hypoglycaemia.
The session may take place in diabetes centres as well as in
local mosques or community centre. The ability to deliver this
session in patients’ own languages is a distinct advantage.
Pre-Ramadan medical assessment
For those wishing to fast during Ramadan, ideally a medical
assessment should take place 2 months before. If this occurs
with a well informed individual and a well informed HCP, then
the outcome is likely to be safer. Many Muslim people with
diabetes are passionate to fast despite their medical condition.
Such passion could be directed to improve diabetes-related
targets and reduce the possible complications, not only for
Ramadan but throughout the year. Indeed, such a policy could
improve the engagement of people with diabetes from ethnic
backgrounds and consequently improve their self-management
of diabetes.
Individual risk quantification of fasting Ramadan
A discussion should take place between an experienced and
well informed HCP and the person with diabetes regarding
their own risk and treatment needs.
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Table 2.  General approaches to glucose-lowering therapy during
Ramadan
Insulin
• Long acting insulin
Give at Iftar (breaking the fast meal) time. Reduce dose if
well controlled.
• Short acting insulin
Adjust dose according to meal size and carbohydrate con-
tent. Reduce Suhur (beginning of fast meal) dose if well
controlled.
• Mixed insulin
Give larger dose at Iftar (evening) and smaller dose at
Suhur (morning). Reduce Suhur dose if well controlled.
Choose type of mixed insulin according to meal size.
A recent study showed that the combination of Humalog-
mix50 at Iftar and Novomix30 at Suhur was better that
Novomix30 at both meals.15
Sulphonylureas
In general, second generation sulphonylureas such as glicla-
zide, glimepiride and glipizide may be associated with a lower
risk of hypoglycemia than glibenclamide.16,17 The general risk
of hypoglycaemia is generally high but could be reduced if
patients receive Ramadan-focused structured education.3
Meglitinides
The rapid onset and short duration of action of this group of
insulin secretagogue drugs allows them to be taken before/
with meals and have a lower association with hypoglycaemia
than sulphonylureas18 and could therefore be of benefit for
people with diabetes wishing to fast.
Incretins
These newer groups of drugs provide possible benefits for
people fasting as they have a lower risk of hypoglycaemia than
sulphonylureas or insulin.19
• DPP4 inhibitors. A retrospective audit on people with
type 2 diabetes undertaking fasting Ramadan while on
metformin and vildagliptin showed that the frequency
of hypoglycaemic events was less than that observed
in people on the combination of metformin and
gliclazide.20 The glycaemic control and the weight in
both group was not significantly different.20
• GLP-1 mimetics. A small study in people with type 2
diabetes during fasting Ramadan showed that the
combination of metformin and exenatide was associated
with a lower incidence of hypoglycaemia than the
combination of metformin and gliclazide.21 This occurred
while the glycaemic control was similar in both groups.21
(Continued)
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Table 2.  (Continued)
However, more studies are required to establish the exact role
of these newer groups of drugs in the management of people
with diabetes during fasting Ramadan.
Key: DPP4 = dipeptidylpeptidase 4, GLP-1 = glucagon-like peptide-1
Medication changes for a safer Ramadan
While there are no large randomised controlled trials to assess
the safety and efficacy of the various glucose lowering drugs
for people with diabetes who are fasting during Ramadan, in
general terms, it is advisable to try to avoid drugs or prepara-
tions that can increase the risk of hypoglycaemia. This is an
easier option now with the availability of several agents with
differing cellular mechanisms of action and drug release formu-
lations. Indeed, this is in line with the general advice of the
latest NICE14 guidelines, which advocates that the choice of a
drug should be based not only on glycaemic control but also
on assessment of the risk of hypoglycaemia and weight gain
for the individual.
While a prolonged fast could be a risk for people on hypo-
glycaemic agents, the social habits during Ramadan could be a
risk for postprandial hyperglycaemia. Unfortunately, many HCPs
advise reducing glycaemic control medication during Ramadan
in order to avoid hypoglycaemia.1 This practice should be
restricted to people with tight glycaemic control on agents that
can lead to hypoglycaemia. The timing of medication needs
to be modified according to the type of drug, however, dose
adjustment will vary according to individual glycaemic control.
Some general pointers for use of glucose lowering medications
during Ramadan are listed in table 2.3,15-21
Pregnancy and fasting in people with diabetes
The Qur’an exempts pregnant and breast feeding women from
fasting in the absence of diabetes. Obviously, pregnant women
with diabetes are at a higher risk. Hence, guidelines for the
management of diabetes in Ramadan strongly advise against
fasting in this group of women.2,22
Conclusion
The Qur’an and Islamic teachings allow many people to be
exempt from fasting Ramadan. This applies to many people
with diabetes. However, many people with diabetes fast
Ramadan regardless of their medical condition. Consequently,
HCPs working in areas with a significant proportion of Muslim
people with diabetes should be aware of Ramadan and its
regulations. Indeed, HCPs should be trained on how to manage
a safer fasting during Ramadan for people with diabetes.
Similarly, Ramadan-focused structured education should be
made available for these groups of people with diabetes. The
choice of medication should be tailored to accommodate the
higher risk of hypoglycaemia associated with long hours of
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Achieving Best Practice
Key messages
● Medical and religious advice concur that fasting
Ramadan should not be undertaken
   during pregnancy
  during illness, e.g. diabetes with other health-risk
issues, or
   with inadequate glycaemic control
● Ramadan-focused diabetes education improves patient
outcomes
fasting, as well as the possible excess postprandial hypergly­
caemia following eating. More research is required on medical
management for fasting Ramadan and diabetes as there is a
lack of strong evidence-based practice.
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