Section 1: Introduction to

Diabetes and Ramadan

Learning Objectives
After completing this section, you should be able to:

Discuss the global impact of diabetes and Ramadan

Elaborate on diabetes and Ramadan, exemptions and

religious opinions

Explain the epidemiology and physiology of diabetes and

Ramadan fasting
Overview
• Worldwide prevalence of diabetes along with the number of fasting Muslims is
increasing
‒ Hence, there is a need for effective guidelines for the management of
diabetes during Ramadan
• Dearth of evidence-based medicine
‒ Most of the recommendations are based on expert opinion rather than clinical
evidence

The IDF-DAR Practical Guidelines provide the HCPs with insights on background and practical information along with
management recommendations to enhance the care delivered to people with diabetes who plan to fast during Ramadan.

HCP, healthcare professional; IDF-DAR, International Diabetes Federation-Diabetes and Ramadan.

Diabetes in Muslim-Majority Countries
The growing problem of diabetes in Muslim-majority countries
North America: Estimated Europe: Estimated Asia-Pacific: Estimated
Muslim population (2010): Muslim population (2010): Muslim population (2010):
3,480,000 43,470,000 986,420,000
Proportion of world Proportion of world Proportion of world
Muslim population: 0.2% Muslim population: 2.7% Muslim population: 61.7%

Europe
18.9%
South-East Asia
36.6%
Middle East and North Africa
North America and Caribbean
103.7% 79.1%
Western Pacific
Africa
140.8%
64.9% South and Central America

Latin America Caribbean: Estimated
Muslim population (2010):
840,000
Proportion of world
Muslim population: <0.1%
Sub-Saharan Africa: Estimated
Muslim population (2010):
248,420,000
Proportion of world
Muslim population: 15.5%
Middle East-North Africa:
Estimated Muslim population
(2010): 986,420,000
Proportion of world
Muslim population: 19.8%

Figures indicate projected increase in diabetes between 2015 and 2040

Global Impact of Diabetes
Number of people (aged 20-79 years) with diabetes, globally, and by IDF region

Europe
2045 68 million
2030 66 million
15%
increase
North America and Caribbean 2019 59 million
2045 63 million
2030 56 million
33%
increase
2019 48 million
South-East Asia
2045 153 million
2030 115 million
74%
increase
2019 88 million
South and Central America
2045 49 million
2030 40 million
55%
increase
2019 32 million

Middle East and North Africa Western Pacific

Africa 2045 108 million 2045 212 million
2030 76 million
96% 2030 197 million
31%
2045 47 million increase increase
2030 29 million
143% 2019 55 million 2019 163 million
increase
2019 19 million
Ramadan – One of the Five Pillars of
Islam
• Ramadan – holy month for Muslims; the time when the Quran was revealed to Prophet Muhammad
• Fasting during Ramadan – one of the five pillars of Islam; time when Allah’s rewards for any good deeds are much
higher than in any other time
• Lasts for 29-30 days – in this period, consumption of food and drinks, along with oral and injected medications, is
forbidden from dawn to dusk
• Each period of fasting may last up to 20 hours, depending on the season and geographic location
• Participation and rewards for good deeds are highest during Ramadan

The Holy Quran says that:

‘Whoever witnesses the month (of Ramadan) then he/she should fast. But, if any of you
is ill or travelling – then he or she is exempted from fasting’ and ‘the missed fast should
be completed at another time’.
Ramadan – Exemptions of Fasting

The Holy Quran says that:

‘Whoever witnesses the month (of Ramadan) then he/she should fast. But, if any of you is ill or
travelling – then he or she is exempted from fasting’ and ‘the missed fast should be completed at
another time’.

Exempted categories include children, the sick, travellers, women during

menses and anyone with reduced mental capacity.
Pregnant and breastfeeding women have the right to not fast regardless of whether they
have diabetes.
Exemptions From Fasting During
Ramadan
It is essential to ensure that those who do not fast due to their medical conditions understand that they
are indeed equally rewarded like those who fast and should not feel guilty.

What constitutes medical exemption?

• Religious scholars often depend on expert advice
• Complicated medical jargon can be hard to interpret
• Religious scholars and medical practitioners must come together through education, outreach and
consensus
Religious Recommendations on
Fasting During Ramadan
Harmony between medical and religious advice is essential to ensure safe fasting for people with diabetes. HCPs,
religious authorities, as well as people with diabetes, need to be made aware of these regulations through all possible
avenues.

The religious recommendations on fasting during Ramadan have been based on:

1. Avoiding hardship
2. Eliminating potential harm

If obvious contraindications are present, HCPs must give categorical advice against fasting.

HCPs, healthcare professionals.

Diabetes and Ramadan – Exemptions
of Fasting
Some of the individuals with diabetes can be exempted from fasting.

As diabetes is metabolic in nature, any major changes in the diet and fluid intake leads to an increased risk of complications such as
• Hypoglycaemia
• Hyperglycaemia
• Dehydration
• Acute metabolic complications such as diabetic ketoacidosis

Despite the exemption, many people with diabetes fast during Ramadan.

In such cases, Ramadan may help in strengthening the therapeutic association between the individual and the physician.

It may also provide an opportunity to improve diabetes management, with a focus on self-care, medicine regulation and mealtime.
Epidemiology of Diabetes and
Ramadan Fasting
EPIDIAR Study

• Only 67% of people with T1DM and 37% with T2DM were
self-monitoring their blood glucose levels
• 42.8% of people with T1DM and 78.7% of people with Type 2 diabetes
T2DM fasted for at least 15 days during Ramadan
• Half of the study population did not change their lifestyle
during Ramadan
• Medical advice was provided to 68% of people with T1DM
and 62% of people with T2DM; majority of people did not Type 1 diabetes
change their medication dose
• The number of hyperglycaemic episodes was also
significantly higher during Ramadan in people with T2DM 0 20 40 60 80 100
% Muslim patients with diabetes who fast for at least 15 days

EPIDIAR, Epidemiology of Diabetes and Ramadan; T1DM, type 1 diabetes mellitus; T2DM, type 2 diabetes mellitus.
Epidemiology of Diabetes and
Ramadan Fasting
Multi-country, retrospective, observational study of the management and outcomes of people with T2DM during
Ramadan (CREED)

• 96.2% of physicians provided advice to people fasting 100

90

Guidelines/recommendations(%)
with diabetes
80
• Guidelines/recommendations were used by 62.6% of
70

Physician using
physicians 60
• Recommendations collaborated with ADA were the most 50
commonly used 40
• Physicians reported the risk of adverse events using the 30
20
ADA recommendations – 33.3% of people were at low
10
risk and 31.4% were at moderate risk 0
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ADA, American Diabetes Association; T2DM, type 2 diabetes mellitus.

Epidemiology of Diabetes and
Ramadan Fasting
Multi-country, retrospective, observational study of the management and outcomes of people with T2DM during
Ramadan (CREED)

• Of the individuals evaluated, 94.2% reported fasting

for at least 15 days during Ramadan and 63.6%
fasted every day during the month 32.4%
63.6%
• This indicates that many people who are at high or 5.9%
very high risk of adverse events still fast during 94.2%
Ramadan, despite the ADA recommendation that ≥15 days (<every day)
those at high risk should avoid prolonged fasting Every day

<15 days ≥15 days

Percentage of patients with T2DM fasting for specific

ADA, American Diabetes Association; T2DM, type 2 diabetes mellitus. period during Ramadan
Epidemiology of Diabetes and
Ramadan Fasting
% of individuals fasting
The proportion of individuals fasting for at least 15 days was fairly
consistent across countries included in the study (90% for 10 of the 100

Number of days
13 countries evaluated)
80
60
The mean number of fasting days was 27, similar to the EPIDIAR study
40
20
0
During Ramadan, 64.1% of people consumed just two meals per day Algeria United Saudi Morocco
Arab Arabia
Emirates
% of individuals fasting

EPIDIAR, Epidemiology of Diabetes and Ramadan.

Epidemiology – CREED Study

At least one episode of hypoglycaemia during

The CREED study reported Ramadan was reported by 8.8% of
39.3% of individuals had a individuals with T2DM compared with 5.4%
that 29.9% of the
change in diabetes regimen before Ramadan and 47.8% of
individuals evaluated also
in preparation for Ramadan hypoglycaemic episodes necessitated
fasted outside of Ramadan
cessation of the fast

T2DM, type 2 diabetes mellitus.

Physiology of Ramadan Fasting
Ramadan marks a sudden shift in mealtimes, sleep and wakefulness patterns, leading to physiological changes in the homoeostatic
and endocrine processes
• Changes in sleeping patterns and circadian rhythms Liver Muscle
• Body weight typically decreases or remains stable during
Ramadan
• In a healthy individual, fasting causes the release of Gluconeogenesis and Pancreas
ketogenesis (T1DM) Glycogen stores depleted
glucose from glycogen stores (glycogenolysis) and the Excessive breakdown
formation of glucose from non-carbohydrate substrates Stimulates Inhibits
(gluconeogenesis)
Insulin secretion
• Ramadan fasting is associated with favourable effects on decreased or absent/
lipid profile in healthy individuals insulin resistance
• Without suitable management, individuals with diabetes
are more likely to experience severe hypoglycaemia Glucose
during Ramadan than in non-fasting periods

T1DM, type 1 diabetes mellitus.

Food
Physiology of Ramadan Fasting
Fasting during Ramadan can lead to metabolic changes and changes in clinical measurements such as blood pressure and
BMI and might help with fatty liver disease.
Holistically, fasting during Ramadan can have positive effects such as improving compassion, empathy and social
interactions.

Fasting during Ramadan can also:

• lead to greater spirituality and mental well-being
• bring both positive and negative psycho-social outcomes to feelings of stress, depression and mood swings

The lifestyle changes that accompany Ramadan such as eating times and diet, physical activity patterns and sleeping
schedules can have different effects on mental and physical well-being.
These should be considered by people with diabetes who are seeking to fast prior to Ramadan and by their HCPs to
advise them

BMI, body mass index; HCPs, healthcare professionals.

Key Takeaways
There is a need for effective guidelines for the management of diabetes during Ramadan.

Harmony between medical and religious advice is essential to ensure safe fasting for people with diabetes. HCPs,
religious authorities, as well as people with diabetes, need to be made aware of these regulations through all possible
avenues.

Sudden shift in mealtimes, sleep and wakefulness patterns, leading to physiological changes in the homoeostatic and
endocrine processes.

Fasting during Ramadan can lead to metabolic changes and changes to clinical measurements such as blood pressure
and BMI and it might help with fatty liver disease.

BMI, body mass index; HCPs, healthcare professionals.

Section 2: Risk Stratification
of Individual With Diabetes
Before Ramadan
Learning Objectives
After completing this section, you should be able to:

Discuss the risks associated with fasting in people with

diabetes

Elaborate on risk quantification and practical guidelines for risk

stratification methodology

Explain the risk categories for people with diabetes who fast
during Ramadan

Explain about the elements for risk calculation and suggested

risk score
Risk Associated with Fasting in
People with Diabetes
Muslims with diabetes who fast face certain challenges as there is a change in the regular diet, physical activity and
medication schedule, which can disturb the metabolic activities.

Risks

Diabetic Dehydration
Hypoglycaemia Hyperglycaemia
ketoacidosis and thrombosis
Although hypoglycaemia and hyperglycaemia affect people with diabetes on a daily basis, fasting may increase the risk of these
events.
Individuals who decide to fast against the advice provided by their HCPs should follow expert and detailed guidance to avoid the
development of serious complications.

HCPs, healthcare professionals.

Clinical Studies
0.16 Before Ramadan
The EPIDIAR Study
During Ramadan
• Higher rates of severe hypoglycaemia during Ramadan compared 0.14*
with before Ramadan
• Higher rates of hyperglycaemia during Ramadan

Ahmedani et al Study
• Symptomatic hypoglycaemia – 35.3% in people with T1DM; 23.2%
in people with T2DM 0.05**
• Symptomatic hyperglycaemia – 33.3% in people with T1DM; 0.03**
15.4% in people with T2DM

HCPs must be cognizant of the risks associated with fasting and Severe Severe Severe Severe
should quantify and stratify them for every individual to provide the hypoglycaemia hyperglycaemia hypoglycaemia hyperglycaemia
T1DM T2DM
best possible care
*p<0.05; **p<0.0001

EPIDIAR study: mean numbers of severe glycaemic events/month during

Ramadan compared with before Ramadan
EPIDIAR, Epidemiology of Diabetes and Ramadan; T1DM, type 1 diabetes mellitus; T2DM, type 2 diabetes mellitus.
Risk Quantification
Type of diabetes
Medications
Factors for risk
quantification

Individual hypoglycaemic risk

Presence of complications and/or comorbidities
Individual social and work circumstances
Previous Ramadan experience

This assessment exercise must be individualised for everyone looking to fast during Ramadan, and personalised care
must be provided accordingly
The Need for Risk Stratification
The CREED study found that more than a third (37.4%) of physicians did not refer to published Ramadan guidelines or
recommendations for management of fasting.

Percentage of physicians that referred to

guidelines or recommendations

37.4
62.6

Referred to one or more guidelines

Did not refer to guidelines
The Need for Better Risk Stratification
HCPs need to consider a range of factors in risk stratification
Ramadan related factors Diabetes related factors
Length of fasting hours Type of diabetes
Season of fasting Duration of diabetes
Weather Diabetic complications
Geographical location Antidiabetic therapies
Social changes Previous control
Proneness to hypoglycaemia
Past experiences Hypoglycaemic unawareness
Access to care
Factors concerning the individual
Age (adolescents and elderly)
Gender
Occupation
Pregnancy/Lactation
Meal pattern
Exercise nature/timing
Motivation
Personal preferences

HCPs, healthcare professionals.

Guidelines for Risk Stratification
Methodology
The experts from the IDF-DAR International Alliance have updated the risk classifications for fasting.

Assigned a risk score for each Review of case scenarios from

Development of several case
Assessment of risk elements risk element based on the 300 experienced diabetes
scenarios to test the tool
literature specialists across the world

The final risk score should be assessed

Pre-Ramadan assessment Each risk element should be The resultant risk score should
alongside the corresponding risk level
assessed sequentially be tallied
and recommendations

The risk stratification criteria have sought and received approval from the Mufti of
Egypt, the highest religious regulatory authority in Egypt.
IDF, International Diabetes Federation-Diabetes and Ramadan.
Elements for Risk Calculation and
Suggested Risk Score
Risk Element Risk Score Risk Element Risk Score
1. Diabetes type 5. Type of treatment
Type 1 diabetes 1 Multiple daily mixed insulin injections 3
Type 2 diabetes 0 Basal bolus/insulin pump 2.5
2. Duration of diabetes (years) Once daily mixed insulin 2
A duration of ≥10 1 Basal insulin 1.5
A duration of < 0 0 Glibenclamide 1
3. Presence of hypoglycaemia Gliclazide/MR or Glimepiride or Repaglinide 0.5
Hypoglycaemia unawareness 6.5 Other therapy not including SU or Insulin 0
Recent severe hypoglycaemia 5.5 6. Self-monitoring of blood glucose (SMBG)
Multiple weekly Hypoglycaemia 3.5 Indicated but not conducted 2
Hypoglycaemia less than 1 time per week 1 Indicated but conducted sub-optimally 1
No hypoglycaemia 0 Conducted as indicated 0
4. Level of glycaemic control not pregnant 7. Acute complications
HbA1c levels >9% (11.7 mmol/L) 5.5 DKA/HONC in the last 3 months 3
HbA1c levels 7.5–9% (9.4–11.7 mmol/L) 3.5 DKA/HONC in the last 6 months 2
HbA1c levels <7.5% (9.4 mmol/L) 1 DKA/HONC in the last 12 months 1
No DKA or HONC 0

DKA. diabetic ketoacidosis; HbA1c, glycated haemoglobin; HONC, hyperosmolar non-ketotic coma.
Elements for Risk Calculation and
Suggested Risk Score
Risk Element Risk Score RISK Element Risk Score
8. MVD complications/comorbidities 11. Frailty and cognitive function
Unstable MVD 6.5 Impaired cognitive function or Frail 6.5
Stable MVD 2 >70 years old with no home support 3.5
No MVD 0 No frailty or loss in cognitive function 0
9. Renal complications/comorbidities 12. Physical labour
eGFR < 30 mL/min 6.5
Highly intense physical labour 4
eGFR 30–45 mL/min 4
Moderate intense physical labour 2
eGFR 45–60 mL/min 2
No physical labour 0
eGFR >60 mL/min 0
13. Previous Ramadan experience
10. Pregnancy*
Pregnant not within targets 6.5 Overall negative experience 1
Pregnant within targets 3.5 No negative or positive experience 0
Not pregnant 0 14. Fasting hours
≥16 hours 1
<16 hours 0
*Pregnant and breastfeeding women have the right to not fast regardless of whether they have diabetes.
eGFR, estimated glomerular filtration rate; MVD, macrovascular disease.
Elements for Risk Calculation and
Suggested Risk Score
The new IDF-DAR risk stratification defines 3 risk categories and provides a risk score that includes multiple factors
that play an important role in the fasting recommendation for each category.
For a given individual, each risk element should be assessed, and the score should be totalled. The resulting score will
determine the overall risk level for an individual with diabetes that is seeking to fast during Ramadan.

SCORE 0-3 LOW RISK

SCORE 3.5-6 MODERATE RISK

SCORE >6 HIGH RISK
Medical and Religious Risk Score
Recommendations
Risk Score/Level Medical Recommendations
LOW RISK 0-3 points Fasting is probably safe
1.Medical evaluation
2.Medication adjustment
3.Strict monitoring
MODERATE RISK Fasting is probably safe
3.5-6 points 1.Medical evaluation
2.Medication adjustment
3.Strict monitoring
HIGH RISK >6 points Fasting is probably unsafe
The resultant score should be measured alongside each category.
Religious Recommendations
1.Fasting is obligatory
2.Advice not to fast is not allowed, unless patient is unable to fast
due to the physical burden of fasting or needing to take
medication or food or drink during the fasting hours.
1.Fasting is preferred but patients my choose not to fast if they
are concerned about their health after consulting the doctor
and taking into account the full medical circumstances and
patient’s own previous experiences.
2.If the patient does fast, they must follow medical
recommendations including regular blood glucose monitoring.
Advise against fasting
Focus on Special Population
Type 1 Diabetes Geriatrics
• Old age combined with ill health – very high risk
Strategies for the safe fasting of individuals with
• Functional capacity and cognition need to be assessed
T1DM include
• Ramadan-focused medical education • The care provided should be adapted accordingly
• Pre-Ramadan medical assessment including
robust assessment of hypoglycaemia
awareness, following a healthy diet and
physical activity pattern Pregnancy
• Modification of insulin regimen
As hyperglycaemia is associated with increased risk for both
• Frequent SMBG or continuous glucose
mother and baby, pregnant women with pre-existing diabetes or
monitoring
GDM are advised not to fast
Key Takeaways
The risks associated with fasting in people with diabetes are diabetic ketoacidosis, hypoglycaemia, hyperglycaemia,
dehydration and thrombosis.

The factors for risk quantification include type of diabetes, medications, individual hypoglycaemic risk, presence of
complications and/or comorbidities, individual social and work circumstances and previous Ramadan experience.

The IDF-DAR guidelines categorise people with diabetes into three risk groups – very high risk, high risk and moderate
risk/low risk. The new IDF-DAR risk stratification defines 3 risk categories and provides a risk score that includes
multiple factors that play an important role in the fasting recommendation for each category.

The risk can be minimised by attending a pre-Ramadan assessment, regular SMBG, structured education, medication
adjustments and nutritional and exercise advice.

IDF-DAR, International Diabetes Federation-Diabetes and Ramadan; SMBG, self-monitoring of blood glucose.
Section 3: Pre-Ramadan
Education and Ramadan
Nutrition Plan
Learning Objectives
After completing this section, you should be able to:

Discuss the Pre-Ramadan Assessment and targets of

Ramadan-focused diabetes education

Elaborate on key components of a Ramadan-focused

educational programme, impacts of pre-Ramadan education

Describe the main dietary changes required during Ramadan

Diabetes Education for Ramadan
Structured diabetes education provides knowledge to people with diabetes, regarding the effective self-management
of their condition

Targets of Ramadan-focused diabetes education

People with diabetes Healthcare professionals General public

• Glycaemic control • Deliver advice in a culturally • Harmonise the

maintenance
• Lifestyle modification
• Risk minimisation
sensitive manner medical and religious
• Encourage communication advice
• Improve the individual-
doctor relationship
• Provide better overall care
Pre-Ramadan Assessment
Pre-Ramadan education is crucial for safe fasting during Ramadan. More evidence has emerged supporting the use
of pre-Ramadan education to achieve safe fasting during Ramadan.
To stratify risk and develop an individualised
management plan.
All individuals seeking to fast • Detailed medical history
should attend a pre-Ramadan • Aspects of diabetes and ability to self-managing
visit 6-8 weeks before Ramadan. • Presence of comorbidities
• The individual’s prior experience in managing
diabetes during Ramadan fasting
• The individual’s ability to self-manage diabetes
• Other aspects increasing the risk of fasting

A concurrent Ramadan focused
structured education.
SMBG, self-monitoring of blood glucose.
• Risk quantification
• The role of SMBG
• When to break the fast
• When to exercise
• Fluids and meal planning
• Medication adjustments during fasting
Targets of Ramadan-Focused Education
• The objective of Ramadan-focused education is to raise awareness of the risks associated with diabetes and fasting
and to provide strategies to minimise them.
• Ramadan-focused educational programmes have been successful in enabling people with diabetes to maintain and
improve glycaemic control during and after fasting and to experience fewer hypoglycaemic episodes.
Ramadan focused education should aim to target HCPs, people Targets of Ramadan-focused diabetes education
• Diabetes care team
with diabetes that are fasting and members of the general public.
Healthcare • Healthcare support system
All these groups are involved in a collective effort to ensure Professionals (e.g., telephone helpline
service)
Ramadan fasting can be safe.

In circumstances where physical distancing is necessary or in

areas in which access and contact is limited, the use of other People with • Individuals themselves
TARGETS Diabetes • Family and caregivers
methods such as video technology and social media should be
considered.

General • Religious and community

Public leaders
• Community support network
Key Components of a Ramadan-
Focused Educational Programme

Exercise: Light-to-moderate exercise during Medication adjustment during fasting:

Blood glucose monitoring: SMBG helps fasting hours is acceptable during Ramadan. Treatment regimen may require
people with diabetes in effective self- More strenuous exercise should be done in modification during Ramadan to reduce the
management the evening. Tarawih prayers are considered risk of hypoglycaemia while sustaining good
part of regular exercise. glycaemic control
Self-Monitoring of Blood Glucose-
7 Point Guide for Ramadan
When to test?
Number of blood glucose monitoring
differs according to the case.
Having the skills to self-monitor
blood glucose levels can
1. Pre-dawn meal (suhoor)
empower people with diabetes to
2. Morning
effectively self-manage their
3. Midday
disease.
4. Mid-afternoon
5. Pre-sunset meal (iftar)
6. 2 hours after iftar
7. At any time when there are
symptoms of hypoglycaemia or
feelings of being unwell.
Fluids and Dietary Advice
Dietary advice for individuals with diabetes during Ramadan:
Divide the daily calories between Suhoor and Iftar, Plus 1 to 2 snacks if necessary.

• 45% - 50% complex carbohydrates

Ensure meals are well balanced E.g., barley, wheat, oats, millet, semolina, beans, lentils
• 20% - 30% protein
• <35% fat (preferably mono- and polyunsaturated)
Include low glycaemic index, high-fibre foods that release energy slowly before and after fasting • E.g., granary bread, beans, rice
Include plenty of fruit, vegetables and salads
Minimise foods that are high in saturated fats • E.g., ghee, samosas, pakoras
Avoid sugary desserts
Use small amounts of oil when cooking • E.g., olive, canola oil, rapeseed
Keep hydrated between sunset and sunrise by drinking water or other non-sweetened beverages
Avoid caffeinated and sweetened drinks
When to Break the Fast

Hypoglycaemia All patients should break their fast if: Hyperglycaemia

• Trembling • Blood glucose <70 mg/dL (3.9 mmol/L) • Extreme thirst
• Sweating/chills • re-check within 1h if blood glucose • Hunger
70-90 mg/dL (3.9-5.0 mmol/L)
• Palpitations • Frequent urination
• Blood glucose >300 mg/dL
• Hunger (16.6 mmol/L)* • Fatigue
• Altered mental status • Symptoms of hypoglycaemia, • Confusion
• Confusion hyperglycaemia, dehydration or acute illness • Nausea/vomiting
• Headache occur • Abdominal pain

*Consider individualisation of care.

Impact of Pre-Ramadan Education
The positive impacts of Ramadan-focused education

Pre-Ramadan Ramadan-Focused Education

Better self Greater

Sustained
Greater monitoring of empowerment
motivation in
During/Post-Ramadan glycaemic glucose and to fast safely
adhering to
control treatment during
guidance
management Ramadan
Evidence of Benefit of Ramadan-
Focused Diabetes Education
The Ramadan Education and Awareness in Diabetes (READ) study
No. of Hypoglycaemic Events
• 2-hour pre-Ramadan educational programme was provided to people
with T2DM 40
• Significant reduction in hypoglycaemic events (from nine events pre- 30
Ramadan to five events during Ramadan)
20
• Weight loss was also observed during Ramadan
10
The Ramadan Diabetes Prospective Study 0
Group A (Provided Group B (Not provided
• A downward trend was observed in the symptomatic hypoglycaemic
with Ramadan-focused with Ramadan-focused
episodes
Education) Education)
• Altering drug dosage, dietary counselling and education, together with
regular blood glucose monitoring helped people with diabetes to fast Pre-Ramadan Ramadan
without major complications
Impact of Pre-Ramadan Education
El Toony et al.
• Education sessions for 6-8 weeks before Ramadan;
• Found reduced incidence of hypoglycaemia and improved glycaemic control

Al-Ozairi et al.
• Individuals using MDI or CSII using the DAFNE method of education; found reductions in hypoglycaemic events with no severe
events or hospitalisations

Hassanein et al.
• High risk individuals receiving pre-Ramadan education for 4-6 weeks before Ramadan; improved glycaemic control, no notable
changes to biochemical or biometric measures

Pooled meta-analysis from Gad et al.

• Showed pre-Ramadan education was associated with reductions in HbA1c levels during Ramadan fasting
Impact of Pre-Ramadan Education
A Forest plot showing the effect of pre-Ramadan education on HbA1c levels during Ramadan from 9 studies.
MEAN DIFFERENCE IV, Random, 95% CI

Overall effect: a reduction of 0.13%

[95% CI -0.46, -0.20] during Ramadan

-2 -1 0 1 2
HbA1c, glycated haemoglobin; IV, intravenous.
Ramadan Nutrition Plan (RNP)
• RNP is a mobile and web-based application to help HCPs individualise and implement MNT for people with diabetes during Ramadan
• Helps individuals to develop a healthy eating plan for Ramadan
• Helps in risk of hypoglycaemia, hyperglycaemia, dehydration, hypertension and dyslipidaemia reduction during Ramadan
• People with diabetes who are fasting, consume an adequate amount of calories, with balanced proportions of macronutrients, during the
non-fasting period (i.e., sunset to dawn) to prevent hypoglycaemia during the fasting period

RNP helps to plan a daily caloric target that may aid It provides examples of meal plans within the target caloric
healthy weight maintenance by losing/gaining weight. levels, designed for use in different countries. Individuals with
Daily
diabetes equally distribute their carbohydrate intake among
1200 kcal 1500 kcal 1800 kcal 2000 kcal
caloric meals to minimise postprandial hyperglycaemia.
intake
1 cup of vegetables 2 teaspoons of oil
Effect Weight Weight Weight Weight
reduction for maintenance maintenance maintenance
women <150 for women for women for women 1/3 cup of 4 oz of lean protein
cm tall <150 cm tall >150 cm tall >150 cm tall beans/lentils/peas
& weight & weight & for men 1 glass of low-fat milk
reduction for reduction for
women >150 men
cm tall
1.5 cup of whole grain
rice 1 small slice of
watermelon
1-2 dates
The RNP as a Global Resource

Access the online version at

www.daralliance.org and then click on your
country in the online map to view a full
nutrition plan (example map above). The
nutrition plan should be printed and handed
to individuals that are seeking to fast during
Ramadan.
Pre-Ramadan Assessment and RNP
The pre-Ramadan assessment should include medical nutrition therapy.

Provide information on
Guidance on how Provide an individualised
how to prevent Help individuals to lose
medical nutrition nutrition plan to reduce
dehydration and other weight successfully if
therapy can improve feelings of lethargy and
diabetes related that is their goal.
glycaemic control. lack of energy.
complication.
Minimising Risks with MNT and
The RNP
For people with diabetes, there are potential risks associated with prolonged fasting. It is crucial to increase the
awareness of these risks to all people with diabetes seeking to participate in Ramadan fasting.

Many diabetes-related risk can be minimised through proper nutrition including

1. Hypoglycaemia, especially during the late period of fasting before Iftar
2. Severe hyperglycaemia after each of the main meals
3. Dehydration, especially in countries with longer fasting hours and hot climates; physical activity
4. Electrolyte imbalances
5. Acute renal failure in individuals prone to severe dehydration, particularly the elderly and those with impaired
kidney function

MNT, medical nutrition therapy; RNP, Ramadan Nutrition Plan.

Health Issues During Ramadan
Large meals
>1500 calories
Large amounts of
Changes in exercise highly processed
and sleeping patterns carbohydrates and
sugar

Fried
foods or foods high in Hyperglycaemia Sugary desserts
trans or saturated fats Hypoglycaemia
Dehydration
Large amounts of high
Large and frequent
GI carbohydrates at
suhoor snacks

Eating Suhoor early Eating too quickly

GI, glycaemic index.

Weight Maintenance and Weight
Reduction During Ramadan Fasting
Table 1: Caloric Targets for Men and Women When Fasting During Ramadan
Weight Maintenance Weight Reduction
Men 1800 – 2200 kcal/day 1800 kcal/day
Women >150 cm tall 1500 – 2000 kcal/day 1500 kcal/day
Women <150 cm tall 1500 kcal/day 1200 kcal/day

Table 2: Caloric and Carbohydrate Distributions for the Ramadan Nutrition Plan
% of calories Carbohydrate distributions
Suhoor 30% – 40% 3 – 5 exchanges
Iftar Snack 10% – 20% 1 – 2 exchanges
Iftar Meal 40% – 50% 3 – 6 exchanges
Healthy Snack (if necessary) 10% – 20% 1 – 2 exchanges

1 Carbohydrate exchange = 15 g Carbohydrates

Weight Maintenance and Weight
Reduction During Ramadan Fasting
RNP caloric guide for weight reduction and weight maintenance (RNP algorithm 1)
Daily caloric 1200 kcal/day 1500 kcal/day 1800 kcal/day 2000 kcal/day
intake

Effect Weight reduction for Weight maintenance for Weight maintenance Weight maintenance
women <150 cm tall women <150 cm tall for women >150 cm for women >150 cm
and weight reduction tall and weight tall and for men
for women >150 cm tall reduction for men
RNP – Carbohydrate Meal Composition
• The total daily intake of carbohydrates should be at least 130 g/day and ideally about
40%-50% of total caloric intake.
Amount
• Intake should be adjusted to meet the cultural setting and food preferences of each
individual.

• Carbohydrates with a low glycaemic index and glycaemic load should be selected.
These include whole grains, legumes, pulses, temperate fruits, green salad and most
vegetables.
CARBOHYDRATES
Recommended • High fibre foods such as unprocessed food, vegetables, fruits, seeds, pulses and
legumes should be consumed. It is recommended to consume about 20-35g/day (or
14g/1000 kcal). Fibre helps to provide satiety during iftar and to delay hunger after
Suhoor.

• The consumption of foods rich in sugar, refined carbohydrate or processed grains and
Not recommended starch foods should be limited; especially sugary beverages, traditional desserts, white
rice, white bread, low fibre cereal and white potatoes.
RNP – Protein Meal Composition
• Protein intake should not be less than 1.2 g/kg of adjusted body weight^ and usually
Amount accounts 20-30% of the total caloric intake. Protein is essential as it enhances satiety
and the sensation od fullness. Protein helps to maintain lean body mass.

Recommended • Fish, skinless poultry, milk and dairy products, nuts, seeds and legumes (beans are
recommended).
PROTEIN

• Sources of protein with a high saturated fat content such as red meat (beef, lamb) and
processed meats should be minimised as they increase the risk of CVD.
Not recommended • Although high-fat dairy products contain saturated fats, a study has shown, increasing
dairy consumption to ≥3 servings/day compared with <3, while maintaining energy
intake, servings/day does not affect HbA1c levels, body weight, body composition, lipid
profile, or blood pressure in patients with T2DM.

CVD, cardiovascular disease; HbA1c, glycated haemoglobin; T2DM, type 2 diabetes mellitus.
RNP – Fat Meal Composition
• Fat intake should be between 30-35% of the total calorie intake. The type of fat is more
important than the total amount of fat in reducing the risk of CVD.
Amount • Limit saturated fat to <7%. PUFA and MUFA should comprise the rest of the fat intake.
• Limit dietary cholesterol to <300 mg/day or <200 mg/day if LDL cholesterol >2.6
mmol/L.

• Consume fat from PUFA and MUFA (e.g., olive oil, vegetable oil or blending oil (PUFA
FAT Recommended and Palm oil). Oily fish (e.g., such as tuna, sardines, salmon and mackerel) as a source
of omega 3-fatty acids are also recommended.

Not recommended • Minimise the intake of foods high in saturated fat including red meat (beef and lamb),
ghee and foods high in trans-fats (e.g. fast foods, cookies, some margarines).

LDL, low density lipoproteins; PUFA: Polyunsaturated fats; MUFA, Monounsaturated fats; CVD, cardiovascular disease.
The Ramadan Nutrition Plate Method
The ‘Ramadan plate’ method should be used for designing meals. A meal should be complete and balanced in
macronutrients.
This meal provides ~500 kcal/meal [45% carbs (3-4 exchanges of carbohydrates)], 20% protein and 35% fat
*Each person may have different plate depending on the daily calorie target
Transcultural Ramadan Nutrition App. (Toolkit)
(Algorithm 2) provides meal plans for 4 caloric levels
and are available online at
https://www.daralliance.org/daralliance/ to support
nutrition needs for each patient with diabetes. These
meal plans are designed for each country to provide
a transcultural experience.
Country-Specific Meal Plans
Ramadan nutrition care plan algorithm 2
Target daily calories
1200 kcal/day
Weight reduction for women <150 cm
height
1500 kcal/day
Weight maintenance for women <150
cm tall and weight reduction for women
>150 cm tall
1800 kcal/day
Weight maintenance for women >150
cm tall and weight reduction for men
2000 kcal/day
Weight maintenance for women >150
cm tall and for men
Country-specific meal plans for the 4 caloric targets: Pakistan and Egypt.
Nutrients Composition and Lifestyle
Recommendations
Carbohydrates
40% - 50%
• (670kcal; CHO exchange = 5)
Recommend low GI. GL. whole grains
and high fibre
Protein
20 – 30%
• Recommend lean meat. Legumes.
Pulses and vegetable protein
Fat
<35%
• Recommend SFA <7% and choose less
fat cooking methods (grilled, baked and
steamed)
Lifestyle Recommendations
• Begin iftar with plenty of water to
overcome dehydration from fasting
• Keep physically active
• Do not sleep for longer than usual
*For a complete Ramadan meal plan and Ramadan plates for other Muslim regions from around the globe, visit website for
Tool kit sample Ramadan nutrition plan for Asia and Middle East
Calories and Carbohydrate
1500 kcal/day Pakistan 1800 kcal/day Egypt
Distributions
540-720 kcal/meal
450-600 kcal/meal
• Beans (foul), Ful: 1.5 cups
• Omelet, 2 egg
• Yoghurt: 1 tub.
Suhoor • Roti (whole meal), 1 small
• Cheese, 2 oz/ 2 slices
30-40% • Milk/lassi, 1 glass
• Small olives, 5 and Salads (cucumber/tomatoes) with 1 egg
(3-5.5 CHO exchanges) • Salad (tomatoes/onions), 1 small bowl
• Whole grain bread, 2 thin slices
• Water, 2 glasses
• Water/unsweetened drink
(500kcal; CHO exchange = 3)
150-240 kcal/meal 150-300 kcal/meal
Iftar Snack
• Fruit, 1 piece @ dates, 1-3 small pieces • Fruit, 1 piece @ dates, 1-3 small pieces
10-20%
• Water/unsweetened drink, 2 glasses • Water/unsweetened drink, 2 glasses
(1-2 CHO exchanges)
(60kcal: CHO exchange = 1) (60 kcal; CHO exchange = 1)
500-240 kcal/meal 620-900 kcal/meal
• Chicken roast, 1 palm size • Salad (Tomatoes. cucumber., greens peas with lemon/vinegar dressing) 1
• Daal/lentil curry, 1 cup medium bowl
Iftar Meal • Vegetable curry, 1 cup • Soup (grilled/broiled chicken/lentil/meat). 4 oz
40-50% • Cooked rice (brown rice). ¾ cup • Cooked vegetables. 1 cup
(3-5.5 CHO exchanges) • Dhai ballah (plain yoghurt with bhundi and vegetables), 1 small bowl • Cooked rice (brown rice). 1 cup
• Side salads • Dessert: 1 small piece
• Water/unsweetened drinks, 2 glasses • Water/unsweetened drinks. 2 glasses
(663 kcal CHO exchange = 45) (825 kcal CHO exchange = 5)
150-300 kcal/meal 180-300 kcal/meal
Healthy Snack • Fruit, 1 piece • Walnuts 1 handful. Cheese
10-20% • Dessert – 1 small (milk-based such as kheer, rasmalai made with sweetener) • 1 glass milk
(1-2 CHO exchanges) • Water/unsweetened drinks, 2 glasses • Water/unsweetened drinks, 2 glasses
(285 kcal CHO exchange = 2) (340 kcal. CHO exchange = 2)
further details www.daralliance.org
Country-Specific Meal Plans
Ramadan nutrition care plan algorithm 2
Target daily calories
1200 kcal/day
Weight reduction for women <150 cm
height
1500 kcal/day
Weight maintenance for women <150
cm tall and weight reduction for women
>150 cm tall
1800 kcal/day
Weight maintenance for women >150
cm tall and weight reduction for men
2000 kcal/day
Weight maintenance for women >150
cm tall and for men
Country-specific meal plans for the 4 caloric targets: Malaysia and China.
Nutrients Composition and Lifestyle
Recommendations
Carbohydrates
• 40% - 50%
Recommend low GI. GL. whole grains
and high fibre
Protein
20 – 30%
• Recommend lean meat. Legumes.
Pulses and vegetable protein
Fat
< 35%
• Recommend SFA <7% and choose less
fat cooking methods (grilled, baked and
steamed)
Lifestyle Recommendations
• Begin iftar with plenty of water to
overcome dehydration from fasting
• Keep physically active
• Do not sleep for longer than usual
*For a complete Ramadan meal plan and Ramadan plates for other Muslim regions from around the globe, visit
website for further details www.daralliance.org
CHO, carbohydrate; GI, glycaemic index; GL, glycaemic load; SFA, saturated fatty acids; tbsp, tablespoon 1 CHO exchange = 15 g CHO
Tool kit sample Ramadan nutrition plan for Asia and Middle East
Calories and Carbohydrate
1500 kcal/day Pakistan 1800 kcal/day Egypt
Distributions
600-800 kcal/meal
300-480 kcal/meal • Noodles, 1 ½ cup
Suhoor • Oats porridge and chicken with vegetables (carrots/broccoli), 1 cup • Beef (lean), 2 pieces
30-40% • Diabetes–specific formula (DSF) 7 scoops/milk 1 glass • Spring onion
(3-5.5 CHO exchanges) • Water/unsweetened drink • Boiled egg, 1 whole
(434kcal; CHO exchange = 3) • Soybean milk (unsweetened), 1 cup
(678kcal; CHO exchange = 5)
120-240 kcal/meal
180-360 kcal/meal
Iftar Snack • Steamed spring rolls with prawn, carrot and yam bean, 1 piece or savoury pancake
• Fruit, 1 piece @ dates, 1-3 small pieces
10-20% • Dates, 1 small piece
• Water/unsweetened drink, 2 glasses
(1-2 CHO exchanges) • Water/unsweetened drink
(60kcal; CHO exchange = 1)
(168kcal: CHO exchange = 2)
800-1000 kcal/meal
480-600 kcal/meal • Salad (Tomatoes. cucumber., greens peas with lemon/vinegar dressing)
• Grilled fish with tamarind sauce, 4 oz 1medium bowl
Iftar Meal • Tempeh with samnal, ½ block • Soup (grilled/broiled chicken/lentil/meat). 4 oz
40-50% • Spinach and mushroom (cooked in soup). 1 cup • Cooked vegetables. 1 cup
(3-5.5 CHO exchanges) • Mango, ½ piece • Cooked rice (brown rice). 1 1/2 cup
• Water/unsweetened drink • Dessert: 1 small piece
(444kcal CHO exchange = 3) • Water/unsweetened drinks. 2 glasses
(905kcal CHO exchange = 5.5)
200-400 kcal/meal
120-240 kcal/meal
Healthy Snack • Walnuts 1 handful. Cheese
• Diabetes-specific formula, 4 scoop blends with 1 date, 1 glass
10-20% • 1 glass milk
• Water/unsweetened drink
(1-2 CHO exchanges) • Water/unsweetened drinks, 2 glasses
(141 kcal CHO exchange = 2)
(340 kcal. CHO exchange = 2)
Key Takeaways
Ramadan-focused diabetes education should be targeted to people with diabetes, HCPs and the general public

Pre-Ramadan educational programmes should be carefully planned to be culturally sensitive and include community and religious leaders to align the medical and religious
messages.
Structured education programmes should include the information on risk quantification, SMBG, diet, exercise and physical activity, medication adjustments and dose testing,
recognition of the symptoms of complications, and when to break the fast to avoid harm.
Studies have demonstrated clear benefits of Ramadan-focused educational programmes on glycaemic control, weight loss, and improving the risk of hypoglycaemia, potentially
even in higher risk individuals.

RNP is a mobile and web-based application to help HCPs individualise and implement MNT for people with diabetes during Ramadan

The RNP provides examples of meal plans within the target caloric levels based on individual needs and tailored for use in different countries.

The RNP website is designed to capture menus from across the globe that match the framework and structure.

The RNP is a work in progress and HCPs from across the globe are encouraged to contribute at http://www.daralliance.org

HCPs, healthcare professionals; MNT, medical nutrition therapy; RNP, Ramadan Nutrition Plan; SMBG, self-monitoring of blood glucose.
Section 4: Management of
Diabetes During Ramadan
Learning Objectives
After completing this section, you should be able to:

Discuss pre-Ramadan individual assessment

Elaborate on medication adjustment during Ramadan

Explain the pharmacological management of high-risk

populations
Medical Management: Sulfonylureas
Studies of sulphonylureas in people with T2DM that fasted during Ramadan

Body weight
Study drug Authors (Date) Study details Hypoglycaemia Glycaemic control changes

≥1 Sus Symptomatic individuals: in ascending order the

(glibenclamide, N=1,378 proportion of events in each group were Gliclazide 14%,
gliclazide, Aravind et al., Study type: Observational glimepiride 16.8% and glibenclamide 25.6%
glimepiride (2011) Countries: India, Israel, Malaysia, UAE, Saudi Arabia Severe events: in ascending order the proportion of severe NR NR
and/or Additional medication(s): Metformin (not all patients) events were Gliclazide 2.6%, glimepiride 5.1 % and
glipizide) Comparators: NR glibenclamide 10.8%

N=557 Symptomatic events: Vildagliptin and gliclazide showed no No significant

Hassanein et al., Study type: Double-blind, randomized controlled trial clear differences (6.0% and 8.7% respectively; p=0.173) No significant changes were observed in difference
Gliclazide (2014) [23] Countries: Bangladesh, Egypt, India, Indonesia, Kuwait, Confirmed events: Vildagliptin was associated with fewer either group between group
Malaysia, Pakistan, Saudi Arabia and UAE., UK events when compared gliclazide (3.0% and 7.0% were observed
Additional medication (s): Metformin, DPP-4 inhibitor respectively; p=0.039)

N=1214
Study type: Real-world observational trial
Countries: Bangladesh, Egypt, India, Indonesia, Kuwait,
Malaysia, Saudi Arabia and UAE
Additional medication (s): Any other OAD or GLP1RA
The proportion of individuals with confirmed HbA1c levels were 7.5% (9.4 mmol/L) pre-
hypoglycaemia during Ramadan was 1.6% (total cases in Ramadan and 7.2% (8.9 mmol/L) post Body weight
all assessment period before, during and after Ramadan Ramadan; change of -0.3% p<0.001 was seen to
1.7%) Fasting Plasma Glucose reduced by 9.7 decrease by 0.5
There were no severe cases of hypoglycaemia during or mg/dL at post-Ramadan compared to pre- kg; p<0.001
after Ramadan Ramadan; p<0.001

The risk of hypoglycaemia is higher than other antidiabetic medications due to its insulin
dependent mechanism of action
Medication Adjustment
Changes to SU dosing during Ramadan

Once-daily dosing Twice-daily dosing Older drugs in the class

Older drugs (e.g. glibenclamide)

Take at iftar Iftar dose remains the same with a higher risk of hypoglycaemia should
be avoided

In patients with well-controlled In patients with well-controlled Second-generation SUs (gliclazide and
BG levels, the dose may be BG levels, the suhoor dose should glimepiride) should be used in preference
reduced be reduced

The risk of hypoglycaemia in those treated with Gliclazide MR seems to be low as shown in a recent study while sustaining
good glycaemic control

BG, blood glucose; SU, sulphonylurea.

Medication Adjustment
SGLT2 inhibitors are considered suitable and safe for some patients during Ramadan

The elderly

Patients with renal impairment

Due to safety concerns, SGLT2 inhibitors are
not recommended for some patients during Hypotensive individuals
Ramadan
Those at risk of dehydration

Those taking diuretics

SGLT2 inhibitors do not require dose adjustment during Ramadan fasting.

It is advised that the dose is taken with iftar.

SGLT2, sodium/glucose cotransporter-2.

Medical Management: Sodium-glucose
Co-transporter-2 Inhibitors Recommendations
For stabilization, SGLT2is should be initiated at least 2 weeks to 1 month prior to Ramadan. SGLT2is are recommended
to be administered at the time of evening meal (Iftar).

Increasing fluid intake during the non-fasting hours of Ramadan is recommended.

When choosing an antihyperglycaemic therapy, the impact on heart failure and renal function must be considered.

SGLT2i do not require treatment modifications during Ramadan.

SGLT2i use when fasting during Ramadan should be in accordance with the usual safety and prescribing measures.

No dose adjustments are required during Ramadan.

SGLT2i, sodium/glucose cotransporter-2 inhibitors.

Medication Adjustment
Changes to metformin dosing during Ramadan

Three times Prolonged-release

Once-daily dosing Twice-daily dosing
daily dosing metformin

• No dose modification • No dose modification • Morning dose to be taken • No dose modification

usually required usually required before suhoor usually required
• Take at Iftar • Take at Iftar suhoor • Combine afternoon dose • Take at Iftar
with dose taken at Iftar

The risk of hypoglycaemia is low for those treated with DPP-4 inhibitors, TZDs, Acarbose, SGLT2i and GLP1-RA .

DPP-4 inhibitors, TZDs, Acarbose, SGLT2i and GLP1-RA DO NOT REQUIRE DOSE ADJUSTMENT during Ramadan
As long as GLP-1 RAs have been appropriately dose-titrated prior to Ramadan (6 weeks
before), no further treatment modifications are required
DPP, dipeptidyl peptidase; GLP1-RA, glucagon-like peptide 1 receptor agonist; SGLT2i, sodium/glucose cotransporter-2 inhibitors; TZDs, thiazolidinediones.
Medical Management: Insulin Therapy
Administration of insulin via the subcutaneous, intramuscular or intravenous routes do not cause a breaking of the Ramadan fast.
Studies assessing the use of basal insulin
Studies evaluating insulin treatments in people with T2DM that fasted during Ramadan

Study drug Authors (Date) Study details Hypoglycaemia Glycaemic control Body weight
changes

N=65
Study type: Observational Individuals experiencing event: No significant difference No change in
Basal insulin: Cesur et al., Countries: Turkey between treatment groups of glimepiride, repaglinide or No significant difference between groups in BMI in any
glargine (2007) Additional medication(s): NR insulin glargine (14.3%, 11.1%, 10.0%, respectively) terms of glycaemic control group was
Comparators: SU (glimepiride), insulin secretagogue No severe episodes were noted identified
(repaglinide)

N=493
Study type: Real-world observational trial
Glargine 300 Hassanein et al., Countries: Canada, Egypt, India, Jordan, Kuwait,
(2020) Lebanon, Pakistan, Qatar, Saudi Arabia Turkey, UAE
Additional medication (s): Any other OAD or GLP1RA
The proportion of individuals with confirmed HbA1c levels were 8.1% (65 mmol/mol)
hypoglycaemia during Ramadan was 2.6% (total cases in pre- Ramadan and 7.6% (60 mmol/mol) Body weight
all assessment periods before Ramadan 2.2%) post Ramadan; change of –o.4% was seen to
There were no severe cases of hypoglycaemia during or Fasting Plasma Glucose reduced by 13.5 decrease by 0.5
after Ramadan mg/dL at post-Ramadan compared to pre- kg
Ramadan

Depending on the type of insulin, there are varying risks for hypoglycaemia and as such different
recommendations are provided.
Medical Management: Insulin Therapy
Administration of insulin via the subcutaneous, intramuscular or intravenous routes do not cause a breaking of the Ramadan fast.
Studies assessing the use of basal insulin
Studies evaluating insulin treatments in people with T2DM that fasted during Ramadan

Body weight
Study drug Authors (Date) Study details Hypoglycaemia Glycaemic control changes

N=245
Study type: Open-label, prospective, randomized
controlled trial Individuals experiencing an event: This in the intervention
Insulin detemir Shehadeh et al., Countries: Israel group (aspart and detemir) had lower risk of Intervention was non-inferior to standard
and biphasic (2015) Additional medication(s): Metformin, SU (not all hypoglycaemia (4.8%) when compared to standard care care in terms of blood glucose levels NR
insulin aspart patients) (ADA recommended regimen) (21.4%), p<0.001
Comparators: Standard care – ADA recommended
insulin regimen

N= The rate of overall hypoglycaemia throughout the

IDegAsp-70% Study type: Phase III open label randomized trial treatment period was statistically significantly lower in the Glycaemic control: Glycaemic control was
insulin Hassanein et al., Countries: Algeria, India, Lebanon, Malaysia and south IDegAsp arm compared with in the BIAap 30 arm, maintained in both treatment arms
degludec and (2018) Africa estimated rate ratio (ERR) 0.26, 95%CI: 0.16-0.44: throughout the study period. NR
30% insulin Additional medication (s): Oral antidiabetic drugs p<0.0001 No statistically significant differences
aspart Comparators: Biphasic insulin Aspart 30. twice daily This corresponded to a 74% reduction in the rate of overall between the arms were reported
hypoglycaemia.

Depending on the type of insulin, there are varying risks for hypoglycaemia and as such different
recommendations are provided.
Medication Adjustment
Ramadan fasting dose adjustments for long- and short-acting insulins in people with T2DM a
Changes to long- and short-acting insulin dosing during Ramadan
Long/Intermediate-acting (basal) insulin Short-acting insulin

NPH/determir/glargine/degludec once-daily Normal dose at Iftar

Reduce dose by 15-30% Omit lunch-time dose
Take at Iftar Reduce suhoor dose by 25-50%
NPH/determir/glargine twice-daily
Take usual morning dose at Iftar
Reduce evening dose by 50% and take at suhoor

Pre-iftar* Post-iftar*/post-suhoor**
Fasting/pre-iftar/re-suhoor blood glucose
Basal insulin Short-acting insulin
<70 mg/dL (3.9 mmol/L) or symptoms Reduce by 4 units Reduce by 4 units
70-90 mg/dL (3.9-5.0 mmol/L) Reduce by 2 units Reduce by 2 units
90-130 mg/dL (5.0-7.2 mmol/L) No changes required No changes required
130-200 mg/dL (7.2-11.1 mmol/L) Increase by 2 units Increase by 2 units
>200mg/dL (11.1 mmol/L) Increase by 4 units Increase by 4 units
a
These recommendations also apply to patient with T1DM.
*Adjust the insulin dose taken before suhoor.
**adjust the insulin dose taken before iftar.
NPH, neutral protamine Hagedorn.
Medication Adjustment
Ramadan fasting dose adjustments for premixed insulin in people with T2DM a
Changes to premixed insulin dosing during Ramadan

Once-daily dosing Twice-daily dosing Three time daily dosing

Take normal dose at Iftar Take normal dose at Iftar Omit afternoon dose
Reduce the suhoor dose by 25-50% Adjust iftar and suhoor dose
Carry out dose-titration every 3 days (see below)

Fasting/pre-iftar/re-suhoor blood glucose Premixed insulin modification

<70 mg/dL (3.9 mmol/L) or symptoms Reduce by 4 units

70-90 mg/dL (3.9-5.0 mmol/L) Reduce by 2 units
90-126 mg/dL (5.0-7.0 mmol/L) No changes required
126-200 mg/dL (7.0-11.1 mmol/L) Increase by 2 units
>200mg/dL (11.1 mmol/L) Increase by 4 units

a
These recommendations also apply to patients with T1DM
Pharmacological Management of
High-Risk Populations
Midday/Noon
 Adults with T1DM, who insist on fasting
should be aware of all the associated risks
and should be under close medical
supervision 12 Midday 12:00
1. Pre-dawn meal (suhoor)
Morning Afternoon 2. Morning
 They should frequently monitor their Suhoor/dawn Iftar/sunset
3. Midday
4. Mid-afternoon
blood glucose levels throughout the day 5. Pre-sunset meal (iftar)
6. 2-hours after iftar
7. At any time when there are
 Adolescents with T1DM who decide to fast symptoms of
(and their parents) must be aware of all hypoglycaemia/hyperglycae
Morning Evening mia or feeling unwell
potential risks associated with Ramadan
12 Midnight 00:00
fasting

Midnight
T1DM, type 1 diabetes mellitus.
Key Takeaways

Individualisation of treatment options is the proper approach for management of diabetes during Ramadan.

Pre-Ramadan patient assessment should include medication adjustment including the choice of the drug, the timing
as well as the dose during Ramadan.

Adults with T1DM or T2DM treated with multiple doses of insulin who insist on fasting should be aware of all
the associated risks and should be under close medical supervision.

T1DM, type 1 diabetes mellitus; T2DM, type 2 diabetes mellitus.

Thank You