Ramadan and Diabetes
Fasting during the holy month of Ramadan is an important spiritual practice. When you have diabetes, you may be wondering how fasting will affect your diabetes. There is a lot of misinformation about diabetes and Ramadan. This handout is written to answer some of the most common questions.
Does everyone have to fast?
No. This is based on the Holy Quran as well as the teachings of Islamic religious scholars over centuries. The Quran states that there are groups of people who do not have to fast, especially if it puts their health at risk. This includes children, pregnant or breastfeeding women, the elderly and anyone who might make themselves ill by fasting. This also includes people with poorly controlled diabetes, people with type 1 diabetes who take insulin or type 2 on a mixed insulin regimen or those who often have very high or very low blood glucose levels.
I know many people with diabetes who fast and don’t have a problem. Is it okay for me?
It is true, many people with diabetes can fast safely, but each person is different. Part of the decision you will make with your doctor has to do with the kind of diabetes medicine you take. It is important to schedule an appointment 2-3 months before Ramadan to discuss how fasting might affect your diabetes. Your doctor or healthcare provider may suggest a change in your medication plan.
What risks should I be aware of?
These are the key risks:
• Low blood glucose (or hypoglycemia) – The risk of blood glucose levels going too low is highest in people taking insulin or certain diabetes pills. Limit physical activity during fasting hours and be more active after sunset. Talk with your healthcare provider to find out if your medicine puts you at risk for low blood glucose and discuss how to prevent it.
• High blood glucose (or hyperglycemia) – While low blood glucose levels may happen during the day, after the fast is broken, there is a greater risk to overeat. Watch out for eating too many sweets and keep the portion sizes moderate. Even though Ramadan is known as a time of fasting – it is not uncommon for people to gain weight during this month, as in some families, every evening meal is a celebration.
• Dehydration – This is especially a problem during the longer and hotter summer days. Aim to drink sugar free and caffeine free drinks frequently throughout the evening and before dawn.
• Low blood glucose (or hypoglycemia) – The risk of blood glucose levels going too low is highest in people taking insulin or certain diabetes pills. Limit physical activity during fasting hours and be more active after sunset. Talk with your healthcare provider to find out if your medicine puts you at risk for low blood glucose and discuss how to prevent it.
• High blood glucose (or hyperglycemia) – While low blood glucose levels may happen during the day, after the fast is broken, there is a greater risk to overeat. Watch out for eating too many sweets and keep the portion sizes moderate. Even though Ramadan is known as a time of fasting – it is not uncommon for people to gain weight during this month, as in some families, every evening meal is a celebration.
• Dehydration – This is especially a problem during the longer and hotter summer days. Aim to drink sugar free and caffeine free drinks frequently throughout the evening and before dawn.
I was told to not check my blood glucose during the day as it will break the fast. Is that true?
Checking blood glucose will not break a fast! It is important to monitor blood glucose levels especially to identify a low glucose level. A fast will have to be ended if glucose levels fall too low (below 70 mg/dl)
How is low blood glucose treated?
If glucose levels do fall below 70, take 15 grams of carbohydrate in the form of one of these: 4 glucose tablets, 6 oz regular soda, 4 oz fruit juice or 1 tube glucose gel. Wait 15 minutes and recheck again. Follow with a snack if the evening meal is not for more than an hour.
Do I stop taking medicine during Ramadan?
No. You continue taking your diabetes medicine, but you will take it at different times. Your dose may also change. This is one reason why it is very important to talk with your healthcare provider several months before Ramadan so you can plan ahead for how your diabetes medicines may need to change.
How do I plan my meals since I’m only eating twice a day?
The dawn meal (Suhoor) should contain a balance of whole grain sources of starchy carbohydrates as well as some protein and fat to help slow the digestion and help the feeling of fullness last as long as possible into the day. Healthy breakfast options good for the hot summer month of Ramadan include:
• Whole grain cereal, low-fat milk, cottage cheese with sliced peaches topped with toasted almonds
• Plain Greek Yogurt flavored with blueberries and cinnamon, whole wheat toast with nut butter.
• Foul (a hearty middle eastern breakfast dish made of lentils or fava beans), small serving of sliced fruit
• Whole wheat roti (unleavened bread) and egg khagina (a southeast Asian dish)
• Whole grain cereal, low-fat milk, cottage cheese with sliced peaches topped with toasted almonds
• Plain Greek Yogurt flavored with blueberries and cinnamon, whole wheat toast with nut butter.
• Foul (a hearty middle eastern breakfast dish made of lentils or fava beans), small serving of sliced fruit
• Whole wheat roti (unleavened bread) and egg khagina (a southeast Asian dish)
Traditionally the fast is broken (Iftar) after sunset and begins with the eating of dates and drinking water. Limit dates to 1-2 each evening. Drink plenty of water and sugar free beverages though out the evening, but avoid caffeine beverages as they can be dehydrating.
While the iftar meal is a celebration time, aim to not overeat. Discuss a plan with your dietitian. Keep sensible portions in mind and follow the same guidelines for healthy eating that you do the rest of the year with an emphasis on whole grains, lean sources of meat, fish and poultry, small amounts of heart healthy fats and limit added sugars.
Ramadan fast can put Muslims with diabetes at risk
Tears ran down the cheeks of an elderly Asian man sitting in his hospital bed during Ramadan last year as he sought reassurance from Muslim chaplain Siddiq Diwan because he could not participate in the annual religious month-long fast.
"I know I am ill and do not have to fast, Imam," the old man said to Diwan at Manchester Royal Infirmary. "But I have never missed one in seven decades, and I really feel bad about it."
While this patient had reluctantly accepted that fasting was not an option for him, thousands of Muslims with diabetes in the UK go ahead regardless. Many will put themselves at risk of serious illness and dangerous complications by taking part in the Ramadan fast (beginning on 28 June) when they go without food, water and even medication between sunrise and sunset – despite the fact that the Qur'an makes exceptions for the sick, pregnant women, children and anyone for whom it would cause physical harm.
As an Imam working at the hospital, Diwan sees the Ramadan dilemma from both sides, and works to resolve issues both in local mosques and among the city's health professionals.
His experiences are echoed in the UK's first study on the beliefs and experiences of Muslims with diabetes during Ramadan, being carried out by Manchester University-based
psychologist
Dr Neesha Patel. The results, published in the journal Health Expectations, highlight the intense pressures felt by individuals with diabetes during the period, from family,culture, religion and their own conscience.
More than half the diabetics in Patel's study still fasted; many continued to do so through a sense of obligation, the need to conform or a belief that the Qur'an demanded it. Some altered their own medication during the period of Ramadan – mostly without the advice of their GP orpractice nurse. Some were put under family pressure to follow the fast, while others felt the need to conceal their decision not to fast by snacking in secret.
This problem will not go away on its own. Patel says: "Ramadan is anannual event – it is going to be with us forever. There is a large Muslim population in the UK and the level of diabetes in some of the communities is many times higher than in the UK generally. This is a big issue. For change to happen there needs to be government support."
The UK has a population of 2.7 million Muslims, of whom 325,000 have diabetes. The South Asian population has six times the general rate of the condition. This year the holy month of Ramadan falls in the summer, and fasters in parts of the northern hemisphere will face periods without food or water that last up to 21 hours. These long periods of abstinence will feature for the next 10 years.
Fasting in itself can sometimes be beneficial to health and for many people Ramadan is an intensely spiritual time. But many health professionals are worried about a lack of formal guidance from Islamic as well as health leaders.
Vascular surgeon Dr Noreen Khan is a practising Muslim from northLondon, interested in fasting, who sees people with end-stage diabetes. She believes that diabetics with good glycaemic control can fast safely if GPs revise their medication at least a month before Ramadan, in some cases temporarily substituting longer-acting drugs.
But she says: "In the UK our scholars and theologians have not been prepared to make any rulings. Muslim scholars should give a consensus and provide all GPs with this information, so that they can give patients both medical and religious guidelines."
GP Dr Faizan Ahmed from Moss Side Family Medical Practice in Manchester agrees there is a need for clarity. He says: "At the moment there is a social stigma in some community groups about not fasting, and the onus is very much on the individual to make a decision."
Since 2010, his practice has invited all patients known to be Muslim for a pre-Ramadan review of their health and medication. This he described as a "watershed", with fewer patients ending up in A&E since, and some taking the decision for the first time not to fast because of their health problems.
In the absence of national health guidelines, Diabetes UK, in collaboration with the Muslim Council of Britain, has produced culturally-sensitive material for people who want to fast, and scripts for Imams. This year the charity is sending volunteers into five largely Islamic areas during Ramadan, with the aim of reducing diabetic complications.
Maslaha – an organisation which aims to help Muslims with the dilemmas of living in a western society – has produced award-winning medical and Islamic information in partnership with Tower Hamlets primary care trust about safe fasting.
Medical training does not cover Ramadan. Trainee GP Dr Iyegbe Iredia admits that as a Catholic she was taken aback by her first patient queries about Ramadan: "I would encourage people to fast if they want to, but the advice is all a bit ad hoc at the moment. GPs need clear guidelines, and it would be good to have somewhere to send complex Muslim patients for expert advice."
What does the act of fasting during Ramadan represent in Islam?
Ramadan is important for practicing Muslims, as it is one of the five pillars of Islam and the month in which the holy Quran was revealed. During Ramadan, Muslim people only eat two meals per day, once before sunrise (sehar) and one after sunset (iftar).
Should all Muslims fast during Ramadan?
The Islamic law states that the ‘sick’ can be exempt from fasting for one or all 30 days and give money to the poor, but some Muslims with diabetes may not perceive themselves as being ‘sick’ and will choose to fast. A tension will often exist among Muslims with diabetes who wish to observe Ramadan in accordance with their faith and the competing need to manage their health. This was evident in my recent research, which was the UK's first study on the beliefs and experiences of Muslims with diabetes during Ramadan.
Are there health benefits to fasting?
Fasting during Ramadan is a spiritual time that is believed to teach morals, self-discipline and a time for reflecting on one’s relationship with Allah and fellow people. Currently there are no national guidelines on the benefits of fasting for people with diabetes but there is some evidence to suggest that fasting may be beneficial to health in the general population.
Are there any health risks?
As Ramadan currently falls in the summer and spring months, and will do for the next eight years, daylight lasts between 17 and 19 hours, thus increasing the number of fasting hours. This poses extreme difficulty for Muslims with diabetes that need to eat and take medication regularly to maintain glyceamic control.
Short-term risks of fasting include poor diabetes control (high or lowblood sugars levels) and dehydration.
Long-term risks include mortality, morbidity and reduced quality oflife, but this needs further research to assess the size of the problem in the UK.
Some guidelines have been developed by clinicians working in diabetes to help identify patients at high, moderate and low risk with recommendations for education and pre-Ramadan medical assessments for all Muslim patients wishing to fast, in order the reduce the above risks.
What advice would you give to diabetic Muslims?
To contact Diabetes UK as they have produced culturally-sensitive material, in collaboration with the Muslim Council of Britain on managing diabetes safely for people who wish to fast. Diabetes UK also recommend that people discuss fasting with their General
Practitioner
for practical advice on altering their diet and medications, and to speak to their Imam, as Imams often provide support and guidance in accordance with the Quran.
What does the act of fasting during Ramadan represent in Islam?
Ramadan is important for practicing Muslims, as it is one of the five pillars of Islam and the month in which the holy Quran was revealed. During Ramadan, Muslim people only eat two meals per day, once before sunrise (sehar) and one after sunset (iftar).
Should all Muslims fast during Ramadan?
The Islamic law states that the ‘sick’ can be exempt from fasting for one or all 30 days and give money to the poor, but some Muslims with diabetes may not perceive themselves as being ‘sick’ and will choose to fast. A tension will often exist among Muslims with diabetes who wish to observe Ramadan in accordance with their faith and the competing need to manage their health. This was evident in my recent research, which was the UK's first study on the beliefs and experiences of Muslims with diabetes during Ramadan.
Are there health benefits to fasting?
Fasting during Ramadan is a spiritual time that is believed to teach morals, self-discipline and a time for reflecting on one’s relationship with Allah and fellow people. Currently there are no national guidelines on the benefits of fasting for people with diabetes but there is some evidence to suggest that fasting may be beneficial to health in the general population.
Are there any health risks?
As Ramadan currently falls in the summer and spring months, and will do for the next eight years, daylight lasts between 17 and 19 hours, thus increasing the number of fasting hours. This poses extreme difficulty for Muslims with diabetes that need to eat and take medication regularly to maintain glyceamic control.
Short-term risks of fasting include poor diabetes control (high or lowblood sugars levels) and dehydration.
Long-term risks include mortality, morbidity and reduced quality oflife, but this needs further research to assess the size of the problem in the UK.
Some guidelines have been developed by clinicians working in diabetes to help identify patients at high, moderate and low risk with recommendations for education and pre-Ramadan medical assessments for all Muslim patients wishing to fast, in order the reduce the above risks.
What advice would you give to diabetic Muslims?
To contact Diabetes UK as they have produced culturally-sensitive material, in collaboration with the Muslim Council of Britain on managing diabetes safely for people who wish to fast. Diabetes UK also recommend that people discuss fasting with their General
Practitioner
for practical advice on altering their diet and medications, and to speak to their Imam, as Imams often provide support and guidance in accordance with the Quran.
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