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Fasting Guidelines to Diabetics

Fereidoun Azizi, and Behnam Siakolah, MD
Endocrine Reseach Center, Shaheed Beheshti University of Medical Sciences, IRAN

During the last two decades, a better understanding of pathophysicological changes during Ramadan fasting in diabetic patients has provided a few guidelines on how to advise diabetics who want to fast. Physicians working with Muslim diabetics should employ certain criteria to advise their patients regarding the safety of Ramadan fasting.

The following criteria should be helpful in making such a decision:
Forbid fasting in:

All brittle type I diabetic patients;
Poorly controlled type I or type II diabetic patients;
Diabetic patients known to be incompliant in terms of following advice on diet drug regimens and daily activity;
Diabetic patients with serious complications such as unstable angina or uncontrolled hypertension;
Patients with a history of diabetic ketoacidosis;
Pregnant diabetic patients;
Diabetic patients will inter-current infections;
Elderly patients with any degree of alertness problems;
Tow or more episodes of hypoglycemia an/or hyperglycemia during Ramdan.

Allow fasting in:

Patients who do not have the aforementioned criteria;
Patients who accept medical adicsement.

Encourage fasting in:

All overweight NIDDM patients (except for pregnant or nursing mothers) whose diabetes is stable with weight levels 20% above the ideal weight or body mass index (body weight, kg/height, meters squared) greater than 28.

Education of the diabetics before Ramadan NIDDM patients and IDDM patients who insist on fasting should be given a few recommendations about fasting. They should be forbidden from skipping meals, taking medication irregularly or gorging after the fast is broken.
The principles of pre-Ramadan considerations are:

assessment of physical well being;
assessment of metabolic control;
adjustment of the diet protocol for Ramadan fasting;
adjustment of the drug regimen e.g. change long-acting hypoglycemic drugs to short-acting drugs to prevent hypoglycemia);
encouragement of continued proper physical activity;
recognition of warning symptoms of dehydration, hypoglycemia and other possible complications.

Recommendations during Ramadan fasting

I. Nutrition and Ramadan fasting:
Dietary indiscretion during the non-fasting period with excessive gorging, or compensatory eating, of carbohydrate and fatty contributes to the tendency towards hyperglycemia and weight gain. It has been emphasized that Ramadan fasting benefits appear only in patients who maintain their appropriate diets. Thus, in order to optimize control, diabetics must be reminded to abstain from the high-calorie and highly-refined foods prepared during this month.

II. Physical activity and Ramadan fasting:
Several studies indicate that light to moderate regular exercise during Ramadan fasting is harmless for NIDDM patients. It has been shown that fasting does not interfere with tolerance to exercise. It should be impressed upon diabetic patients that it is necessary to continue their usual physical activity especially during non-fasting periods.

III. Drug regimens for IDDM patients:
Some experienced physicians conclude Ramadan fasting is safe for IDDM patients with proper self-monitoring and close professional supervision. It is fundamental to adjust the insulin regimen for good IDDM control during Ramadan fasting. Two insulin therapy methods have been studied successfully:

Three-dose insulin regimen: two doses before meals (sunset and Dawn) of short-acting insulin and one dose in the late evening of intermediate- acting insulin.
Two-dose insulin regimen: Evening insulin combined with short-acting and medium-acting insulin equivalent to the previous morning dosage, and a pre-dawn insulin consisting only of a regular dosage of 0.1-0.2 unit/kg.

Home blood glucose monitoring should be performed just before the sunset meal and three hours afterwards. It should also be performed before the pre-dawn meal to adjust the insulin dose and prevent any hypoglycemia and post-prandial hyperglycemia following over-eating.

IV. Drug regimens for NIDDM patients:

Available reports indicate that there are no major problems encountered with NIDDM overweight patients who observe fasting in Ramadan. With proper changes in the dosage of hypoglycemic agents there will be low risk for hypoglycemia and hyperglycemia.
The authors of the largest series of patients treated with glibenclamide during Ramadan recommended that diabetics switch the morning dose (together with any mid-day dose) of this drug with the dosage taken at sunset.

V. Other health tips for reduction of complications:

Implementation of the 3D triangle of Ramadan - drug regimen adjustment, diet control and daily activity -- as the three pillars for more successful fasting during Ramadan.
Diabetic home management that consists of:
- Monitoring home blood glucose especially for IDDM patients, as described above;
- Checking urine for acetone (IDDM patients);
- Measuring daily diet and informing physicians of weight reduction (dehydration, low food intake, polyuria) or weight increase (excessive calorie intake) above two kilograms;
- Recording daily diet intake (prevention of excessive and very low energy consumption).
Education about warning symptoms of dehydration, hypoglycemia and hyperglycemia.
Education about breaking fast as soon as any complication or new harmful condition occurs.
Immediate medical help for diabetics who need medical help quickly, rather than waiting for medial assistance the next day.
Further attention on fasting during the summer season and geographical areas with long fasting hours.

VI. IDDM children and Ramadan fasting:
We do not encourage fasting for IDDM children. However, a few studies demonstrate that fasting is safe among diabetic adolescents. Of these studies, one study concludes that Ramadan fasting is feasible in older children and children who have had diabetes for a long time, and it concludes fasting does not alter short -term metabolic control. Nevertheless, fasting should only be encouraged in children with good glycemic control and regular blood glucose monitoring at home.

Post-Ramadan supervision of fasting diabetics

After the month of Ramadan ends, the patients therapeutic regimen should be changed back to its previous scheduale. patients should also be required to get an overall education about the impact of fasting on their physiology.

The research methodology on diabetics during Ramadan

From a methodological point of view, few research papers on Ramadan fasting are relevant because of the absence of control periods before Ramadan and afterwards, the absence of measurements during each week of Ramadan, a lack of attention to dietary habits, food composition, food value, caloric control, weight changes and the importance of the schedule during circadian periods.
It is recommended that all these factors should be taken into consideration and that all intervening and confounding variables should be under control. It is clear that more work should be done on Ramadan fasting to evaluate physiological and pathological changes with proper research methods.

Fasting during the entire month of Ramadan is reserved usually for healthy Muslims. However, many diabetic patients are allowed to fast periodically during Ramadan. The magnitude of periodic total fasting effect on blood glucose and hepatic glucagon depends on the number of fasting days, and this should be considered in all Ramadan fasting research activities.

Conclusion

The bulk of literature indicates that fasting in Ramadan is safe for the majority of diabetics patients with proper education and diabetic management. Most NIDDM patients can fast safely during Ramadan. Occasional IDDM patients who insist on fasting during Ramadan can also fast if they are carefully managed. Strict attention to diet control, daily activity and during regimen adjustment is essential for successful Ramadan fasting.

To shed more light on pathophysiological changes in Ramadan fasting, in particular in Muslims diabetics, it is recommended that a multicentric international controlled clinical trial be employed to assess the effect of differences in gender, races, physical activities, food habits, sleep patterns and other important variables on physiologic and pathologic conditions during Ramadan fasting

Posted on January 23, 2005

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