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Navigating Diabetes throughout Ramadan

What is Ramadan?

Ramadan is the ninth and most sacred month of the Islamic calendar and involves daylight fasting, prayer, reflection and celebration of community. All adult Muslims are required to refrain from eating and drinking and also abstain from oral medications between sunrise and sunset for 30 days. Although individuals who may become ill by fasting (like those with diabetes) are exempt from Ramadan, many choose to fast with their community. Therefore, it is very important that those with diabetes understand how they can achieve a healthy and safe Ramadan.
So, how does Ramadan affect optimal blood glucose control?

Fasting between sunrise to sunset during Ramadan can be 11 to 20 hours without food and drink. This causes disruption to meal times, sleep and wakefulness patterns and therefore can greatly impact blood glucose level (BGL) control and increase the risk of:

• Low BGLs (hypoglycaemia),
• High BGLs (hyperglycaemia),
• Diabetic ketoacidosis (DKA), and
• Dehydration and blood clots.

These risks are dependent on some background factors and the International Diabetes Federation have categorised these factors into very high risk, high risk and moderate to low risk (detailed in the table below).
Very High RiskHigh Risk

Moderate to Low Risk

• Severe hypoglycaemia < 3 months prior to Ramadan
DKA < 3 months prior to Ramadan
• History of recurrent hypoglycaemia or hypoglycaemia unawareness
• Suboptimal blood glucose levels with type 1 diabetes
• Pregnancy with pre-existing diabetes or gestational diabetes treated with insulin or sulphonylureas 
• Suboptimal BGL control with type 2 diabetes
• Optimal type 1 diabetes
• Optimal type 2 diabetes on multiple dose or mixed insulin
• Pregnancy with pre-existing type 2 diabetes or gestational diabetes treated with diet or metformin

Optimal type 2 diabetes treated with one or more of the following:
• Lifestyle therapy
• Some medications like metformin

Is fasting during Ramadan safe for people with diabetes?
Regardless of the risk category, it is important that people with diabetes who are fasting during Ramadan consult their team of health professionals including their doctor, diabetes educator and dietitian beforehand. Many Muslims unable to fast can compensate by Fidya, which is donating food or money to those who are less fortunate.

Our tips for optimal blood glucose control during Ramadan
We know that eating regularly and spreading intake of carbohydrate foods evenly throughout the day is the best way to assist with maintaining good energy levels and optimal BGLs.

Our tips below will help you to stabilise your BGLs and stay healthy during Ramadan
• Consult your team of health professionals within 8 weeks prior to commencing Ramadan to discuss medication adjustments and reduce your risk of sub-optimal BGLs.
• Check your BGLs at least 3 and 4 times per day for those at high to very high risk of hypoglycaemia and 1 and 2 times a day for those at moderate to low risk of hypoglycaemia.
• Drink plenty of water during the non-fasting period and avoid caffeinated and sweetened drinks to decrease your risk of dehydration. Carry a water bottle with you to encourage frequent sipping.
• Break your fast with a healthy snack like fresh fruit, Greek style yoghurt, vegetable sticks with dip, unbuttered popcorn or wholemeal toast and a glass of water to help settle your hunger, prevent overeating with your main meal and maintain hydration.
• Ensure your evening (Suhoor) and morning (Iftar) meals are substantial and well balanced for BGL stability and fullness. Fill half your plate with non-starchy vegetables, a quarter of the plate with low glycaemic index and high-fibre carbohydrate foods like legumes, wholemeal pasta, semolina, and the final quarter with protein foods like poultry, fish, eggs and dairy.
• Immediately break your fast if you experience symptoms like sweating, dizziness, extreme tiredness, increased thirst, blurred vision or your BGLs are < 4.0mmol/L (as you may be hypoglycaemic) or > 16.6mmol/L (as you may be hyperglycaemic).
• Continue regular or light exercise and be aware of vigorous exercise because this increases the risk of lower BGLs and dehydration.
• Avoid overeating when Ramadan ends as this can cause higher BGLs.

Ultimately, the decision to fast is personal and we highly encourage making an informed choice by consulting your team of health professionals. If you would like individualised information about safely optimising blood glucose levels during Ramadan, book an appointment online at www​.nour​ishadl​.com/​d​i​e​t​itian

Co-authored by student dietitian, Charlotte Manning
Reviewed by dietitian, Rebecca Greco


References
International Diabetes Federation and the DAR International Alliance. (2016). Diabetes and Ramadan: Practical Guidelines. Brussels, Belgium: International Diabetes Federation.

International Diabetes Federation. (2021). Diabetes and Ramadan. Retrieved from https://​idf​.org/​o​u​r​-​a​c​t​i​v​ities.

International Diabetes Federation. (2021). Guidelines for people with diabetes. Retrieved from https://​www​.idf​.org/​o​u​r​-​a​ctivi.

Royal Australian College of General Practitioners (2017). Diabetes Management during Ramadan. Retrieved from https://​www​.racgp​.org​.au/​getat…

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