By Janice Harvey, RPh, CDE
Most people with diabetes can successfully fast during Ramadan, but there are diabetes-specific challenges that occur when abstaining from eating, drinking and taking oral medications from pre-dawn to sunset for the full lunar month. Below are some tips and suggestions to help manage blood sugar levels during this time.
Tip #1: Stay hydrated
It is always important to stay well hydrated, and more so during a long fast. Water plays a big role in our bodies, helping balance electrolytes and aiding in nutrient absorption. Even mild dehydration can lead to headaches, difficulty concentrating, and tiredness. Water is the most obvious choice for getting enough fluids; other options include juices and soups, vegetables and fruits. It is best to avoid calorie-rich drinks that can cause weight gain and caffeinated drinks like coffee and tea that lead to more fluid loss.
Tip #2: Consider your food options
With Ramadan following the lunar calendar and currently taking place in the winter months in Canada, the fasting time can last from 12 to as much as 18 hours. Because of this, hunger can be significant by the end of the fasting time, and this can lead to overeating or making poor food choices.
Just as we may have three meals in a day during the rest of the year, we will still do this during Ramadan. The pre-dawn meal represents breakfast and provides energy for the day, the sunset meal is a light lunch, and the main meal after prayers is supper. For individuals with diabetes, having meals spaced out overnight helps to keep blood sugars more stable.
Breaking the fast with some dates or vegetable soup, which contain fibre as well as natural sugars, will help to normalize blood sugar levels and curb appetite at the main meal. Plan this meal in advance, keeping it light. For the main meal, try to avoid heavy, fatty foods and foods rich in carbohydrates, such as rice or pastries, as these contribute to bloating and stomach discomfort. Sweets provide little nutrition and should be consumed in very limited amounts, especially those containing large amounts of syrup and ghee. Instead, focus on eating foods that are good sources of protein and complex carbohydrates, such as beans, and limit the amount of oils used in food preparation. Eat plenty of fruits and vegetables, as these are rich sources of vitamins, minerals and fibre. Do not skip the pre-dawn meal, as this will only lengthen the fasting time. (1)
Tip #3: Schedule exercise in the morning
Many people exercise after work: on their way home or later in the evening. This is the time when there is the greatest risk of hypoglycemia (low blood sugars). If possible, it is best to exercise after the pre-dawn meal, when you will have energy to exercise and the increase in activity will help to reduce any spike in blood sugars from the meal.
Tip #4: Monitor blood sugar levels throughout the day
One might think fasting levels would go up first thing in the morning, but they generally do not (they might even go down a bit). During Ramadan, it’s the levels after eating that increase the most, especially if the meal consists of mostly carbohydrates. Thus, during Ramadan, blood sugar levels will be high overnight, and there is more risk of low blood sugar levels during the day, especially by late afternoon. Be especially careful not to drive if blood glucose levels are less than 5 mmol/L, as you could experience a low blood sugar event while driving.
Remember, testing does not invalidate the fast. In fact, regular testing may decrease the frequency and severity of hypoglycemia, so it can help to ensure that it is safe to continue to fast. It is recommended that blood sugar levels be checked before the pre-dawn meal, in the morning, around noon, mid-afternoon, before the sunset meal and two hours after that meal, and at any time when you are feeling symptoms of low or high blood sugars. That’s a lot of testing! A continuous glucose monitor (CGM) provides readings throughout the entire day and can reduce worries about low blood sugars while sleeping, during prayers, and when working.
Tip #5: Ask for help with adjusting your medications
There are a few medications that do not need to be adjusted during Ramadan, such as metformin, which has a very low likelihood of causing hypoglycemia. There are also some medications where no adjustment is needed, but they shouldn’t be started before/during Ramadan, such as dapagliflozin or semaglutide. And then there are medications that should be changed to a safer alternative or where at least the dose should be reduced, such as glyburide. Insulin changes are much more complicated, as certain types of insulin are preferred over others, dose reductions can range from 15% to 50%, and the changes can vary by time of day and whether they are being taken with a specific meal. Recommendations for medication adjustments can be found in the Canadian Journal of Diabetes. (2)
Stay healthy during the Holy Month
Fasting during Ramadan is one of the five pillars of Islam and is compulsory for all healthy Muslims from puberty onwards. However, fasting may not be possible for those at high risk of health complications as a result of fasting, so exemptions are made for people with serious medical conditions, including diabetes.
Ideally, individuals with diabetes should meet with their healthcare provider 6 to 8 weeks prior to Ramadan to determine their risk level for fasting and to learn about self-management strategies that will help to ensure success. The Diabetes and Ramadan Practical Guidelines 2021 (3) developed by the International Diabetes Foundation and Diabetes & Ramadan International Alliance, offers significant guidance for managing diabetes during Ramadan and is a great resource for healthcare providers. We want you to be safe and healthy throughout Ramadan. Please consult with your healthcare team about any questions you may have.
Your health. Our priority.