Managing diabetes during Ramadan

By Professor Dr Muhammad Aziz Rahman

One in four people globally is Muslim, and most of them will observe fasting during the upcoming Ramadan. In 2024, the fasting month will begin in the second week of March, subject to the moon's sighting.

Scientific evidence suggests there are benefits of Ramadan to improving physical and mental health by regulating eating and drinking and self-controlling one's attitude while disrupting unhealthy behaviours like smoking and drinking.

For public health professionals, there is an untapped opportunity for planning health promotion campaigns in Muslim communities. People with certain health conditions need to be cautious in fasting, which warrants consultation with their physicians.

One of the key disruptions that happens during Ramadan is fasting for 12-15 hours, which is often challenging for people with diabetes. Many authorities have developed guidelines and recommendations in Australia, including Diabetes Australia, the Royal Australian College of General Practitioners (RACGP), and the Australian Diabetes Society. In addition, the International Diabetes Federation, along with the Diabetes & Ramadan International Alliance (DaR) and Sanofi, released a guide for Ramadan. The following issues need to be considered.

Preparation for Ramadan

A patient with diabetes needs to consult with their general practitioner (GP) about their intention to fast during the upcoming Ramadan. Health professionals can provide advice by considering the individual status of the patient, risk factors, and previous fasting experience. This will be the opportunity for a diabetes educator to educate the patients on planning meals, adjusting medication, self-monitoring blood glucose and guidance on exercise.

Uncontrolled diabetes, pregnancy, and co-morbidities, along with the risk of diabetes complications, categorise a patient as high to very high risk if fasting is planned. If the individual patient's condition does not permit a recommendation for fasting, that should be followed, as there are ways to make up for those fasting, and an Islamic scholar can be consulted in that regard.

Managing medications and self-monitoring

There are several strategies that people with diabetes can follow when they are preparing for Ramadan. As always, they should consult with their GPs as there is no one-size-fits-all approach.

Monitoring blood sugar is very important if any patient with diabetes is fasting to avoid the risk of hypo (low blood glucose) or hyperglycaemia (high blood glucose). Checking blood sugar levels by pricking a fingertip does not invalidate fasting, which Islamic scholars have agreed. Having the blood glucose below 4 mmol/L or above 15 mmol/L warrants breaking of fasting and managing the situation accordingly.

It's also essential that a patient with diabetes is aware of the signs and symptoms of low or high blood glucose. There is a recommendation of timing when to check blood glucose during Ramadan: Suhoor, morning, midday, mid-afternoon, Iftar, two hours after Iftar, and anytime when there will be symptoms of hypo/hyperglycaemia.

Managing food intake

A healthy eating plan is essential to avoid increasing daily consumption or overeating of carbohydrates and fatty food during Iftar. Patients can consider dividing the daily calorie intake between Suhoor and Iftar. Consuming food with a low glycemic index (GI) is important, and foods with saturated fats and refined sugar should be avoided.

Diets should include complex carbohydrates such as multigrain/wholegrain and sourdough bread, porridge, oats, bran, barley, semolina and buckwheat, as well as protein-rich foods such as lean meat, poultry, fish, eggs, dairy products, seeds, nuts, beans, legumes and tofu. Vegetables and salad should be included in the meal plan. To remain hydrated, plenty of fluids should be consumed during Suhoor and after Iftar.

During Iftar, traditional fried foods and sugary drinks should be avoided. Eating dates during Iftar is also a traditional Islamic practice, and the health benefits of eating dates are proven scientifically. However, date intake should also be limited, as two large dates (30g without stones) can provide around 20g of carbohydrates, which is about the same as a medium slice of bread.

Physical activity or exercise

Regular or light exercise can continue during the period of fasting. However, strenuous physical activities should be avoided as there is a risk of hypoglycaemia and dehydration, specifically near the time of Iftar. It is the ritual to attend special night prayers, called Taraweeh, during Ramadan, which can take more than an hour to complete. That ritual can be considered as the daily physical activity during Ramadan. To be prepared for that activity, having low GI food and plenty of water during Iftar is important. A bottle of water can also be accompanied during the prayer time.

Muslims also practice voluntary fasting besides the month-long obligatory fasting. A patient with diabetes should adopt similar approaches during those days of fasting.

Healthcare professionals should be aware of this ritual practice of fasting during Ramadan and should advise patients with diabetes accordingly. Regular training and sensitising them on this issue is critical in Australia's multicultural society.

Professor Dr Muhammad Aziz Rahman is the Research Adviser and Discipline Leader of Public Health at the Institute of Health and Wellbeing. He is a medical doctor, a public health professional and is also a practising Muslim.

Related reading:

Staying healthy during the Ramadan fast