09/06/2014
What are the risks of fasting for people with diabetes?
Most Muslim religious authorities accept that if a person is advised by a trusted health professional (such as a doctor or nurse) that fasting is harmful to his or her health, then that person is exempted from fasting.4 The risks of fasting include hypoglycaemia, hyperglycaemia, and dehydration. The EPIDIAR study found that the change in eating patterns during Ramadan increased the risk of severe hypoglycaemia 4.7-fold (from 3 to 14 events per 100 people per month) in type 1 diabetes and 7.5-fold (from 0.4 to 3 events per 100 people per month) in type 2 diabetes. It also found a fivefold increase in the incidence of severe hyperglycaemia in patients with type 2 diabetes during Ramadan. A small observational study (n=41) conducted in 1998 found an increase in symptomatic hypoglycaemia,5 but other studies have not found a significant increase in the risk of hypoglycaemia during Ramadan in patients treated with oral hypoglycaemic medications or insulin.6 7One explanation for different findings among studies is that because Ramadan occurs in a different season every nine years, and the duration and temperature of fasting days change, rates of hypoglycaemia may vary according to the year in which the study was performed. The differences in methods and the small number of patients included in these studies would also explain the disparity of the results.
Over the coming decade, the number of fasting hours will progressively increase in the northern hemisphere as Ramadan falls in the summer months. This will have important implications for Muslims with diabetes who wish to fast.
How should patients with diabetes who fast for Ramadan be managed?
Assessment before Ramadan
Expert opinion recommends that if a patient has made it clear that they wish to fast during Ramadan their primary physicians and/or diabetes care specialists should assess whether they increase their health risk by doing so.8 Box 1 outlines how patients planning to fast during Ramadan may be categorised as either high, moderate, or low risk of adverse events. Patients classed as high risk are advised not to fast as it can lead to worsening diabetes control, resulting in, for example, severe hypoglycaemia and diabetes ketoacidosis. Patients at moderate risk can reduce their level of risk if they see a healthcare professional several months before Ramadan and make necessary changes to their diabetes treatment. Those at low risk can fast without healthcare advice. Patients who choose to fast despite advice not to do so need support to help them fast as safely as possible.
Box 1 Expert recommendations for risk stratification in patients with type 1 or type 2 diabetes who fast during Ramadan8
Patients at high risk
• Those with severe and recurrent episodes of hypoglycaemia and unawareness
• Those with poor glycaemic control
• Those with ketoacidosis in the three months before Ramadan
• Those who experience hyperosmolar hyperglycaemic coma within the three months before Ramadan
• Those with acute illness
• Those who perform intense physical labour
• Pregnant women
• Those with comorbidities such as advanced macrovascular complications, renal disease on dialysis, cognitive dysfunction, uncontrolled epilepsy (particularly precipitated by hypoglycaemia)
Moderate risk
• Well controlled patients treated with short acting insulin secretogogue, sulphonylurea, insulin, or taking combination oral or oral plus insulin treatment
Low risk
• Well controlled patients treated with diet alone, monotherapy with metformin, dipeptidyl peptidase-4 inhibitors, or thiazolidinediones who are otherwise healthy
In case patients miss the opportunity for assessment before Ramadan, discussion with patients and provision of information packs (see the “Additional educational resources” box) that include advice on Ramadan fasting can be made available at diagnosis and also at annual diabetic review.
Ramadan focused education
Structured education interventions have been endorsed by the National Institute for Health and Clinical Excellence as important in empowering patients to improve their journey with diabetes. In a large observational study, patients who fasted during Ramadan without attending a structured education session had a fourfold increase in hypoglycaemic events, whereas those who attended an education programme focusing on Ramadan had a significant decrease in hypoglycaemic events.9 We therefore recommend that Muslim patients with diabetes attend some form of structured education intervention to increase their chance of being well when fasting during Ramadan. Patients at high risk who plan to fast despite medical advice not to are also invited to attend structured education to support their self management and decision to fast. Box 2 outlines suggested content of Ramadan focused education.
Box 2 Four key areas in Ramadan focused education9
Meal planning and dietary advice
• The diet during Ramadan should be a healthy balanced diet
• Slow energy release foods (such as wheat, semolina, beans, rice) should be taken before and after fasting, whereas foods high in saturated fat (such as ghee, samosas, and pakoras) should be minimised10
• Advise patients to use only a small amount of monounsaturated oils (such as rapeseed or olive oil) in cooking
• Before and after fasting include high fibre foods such as wholegrain cereals, granary bread, brown rice; beans and pulses; fruit, vegetables, and salads
Exercise
• Regular light and moderate exercise is safe in type 2 diabetes patients11
• Rigorous exercise is not recommended as the risk of hypoglycaemia may be increased, particularly in patients taking sulphonylureas or insulin
• Encourage patients to continue their usual physical activity, especially during non-fasting periods
• Tarawaih prayers (a series of prayers after the sunset meal) should be considered as part of the daily exercise regimen as they involve standing, bowing, prostrating, and sitting
Blood glucose monitoring
• Blood glucose monitoring does not constitute the break of fast12
• All patients who fast should be provided with the means to monitor their blood glucose13
• Capillary blood glucose testing should be done when:
o -The patient suspects they have symptoms of hypoglycaemia (subjective to the individual). Patients should be advised to break their fast if hypoglycaemia is confirmed on blood glucose testing
o -The patient is unwell (eg has a fever)
• Testing at other times may be useful only if patients are able and willing to adjust their diabetes treatment regimens, such as insulin dosage titration
Recognising and managing complications
• Patients should be aware of the warning symptoms of dehydration, hypoglycaemia, and hyperglycaemia and should stop the fast as soon as any complications or acute illness occur
