The objective of this review article is to
assist physicians who face the difficult task of advising diabetic patients
about the safety of fasting during the Islamic month of Ramadan.
There have been
diverse findings regarding the physiological impact of Ramadan on diabetics.
However, researchers have not found pathological changes or clinical
complications in any of the following parameters in diabetics who fast: body
weight, blood glucose, HbA1C, c-peptide, insulin, fructoseamine, cholesterol and
triglycerides. In the guidelines section of the article, we strongly recommend
diabetic patients continue their regular daily activity and diet regimen. It is
also critical that diabetics adjust their drug treatments, particularly those
patients diagnosed with insulin dependent diabetes mellitus (IDDM). We named
these three important factors -- drug regimen adjustment, diet control and daily
activity -- the "Ramadan 3D Triangle." With 3D attention, proper
education and diabetic management, we conclude that most non-insulin dependent
diabetes mellitus (NIDDM) patients and occasional IDDM patients who insist on
fasting can carefully observe Ramadan. Int J Ramadan Fasting Res. 2:8-17,
Several of the world's great
religions recommend a period of fasting or abstinence from certain foods. Of
these, the Islamic fast during the Muslim month of Ramadan is strictly observed
every year. Islam specifically outlines one full month of intermittent fasting.
The experience of fasting is intended to teach Muslims self-discipline and
self-restraint and remind them of the plight of the impoverished. Muslims
observing the fast are required to abstain not only from eating and drinking,
but also from consuming oral medications and intravenous nutritional fluids.
The month of Ramadan contains 28 days to 30 days. The
dates of observance differ each year because Ramadan is set to a lunar calendar.
Fasting extends each day from dawn until sunset, a period which varies by
geographical location and season. In summer months and northern latitudes, the
fast can last up to 18 hours or more. Islam recommends that fasting Muslims eat
a meal before dawn, called "sahur." Individuals are exempt from
Ramadan fasting if they are suffering from an illness that could be adversely
affected by fasting. They are allowed to restrain from fasting for one day to
all 30 days, depending on the condition of their illness. People diagnosed with
diabetes fall into this category and are exempt from the fasting requirement,
but they are often loathe to accept this concession. Physicians working in
Muslims countries and communities commonly face the difficult task of advising
diabetic patients whether it is safe to fast, as well as recommending the
dietary and drug regimens diabetics should follow if they decide to fast. The
lack of adequate literature on this subject makes it difficult to answer these
questions. To judge correctly whether to grant medical permission to fast to a
diabetic patient, it is essential physicians have an appreciation of the effect
of Ramadan fasting on the pathophysiology of diabetes mellitus. In this article,
we first review principles of carbohydrate metabolism and alterations of certain
biochemical variables in diabetics observing Ramadan fasting. We then overview
current medical recommendations that allow certain diabetic patients to fast and
outline terms for diabetic patients, particularly IDDM patients, who should not
fast but insist on fasting.
THE PHYSIOLOGICAL STATE OF DIABETICS DURING RAMADAN
Carbohydrate metabolism during Ramadan fasting in healthy persons
The effect of experimental short-term
fasting on carbohydrate metabolism has been extensively studied (1,2). It has
been uniformly found that a slight decrease in serum glucose to 3.3 mmol to 3.9
mmol (60 mg/dl to 70 mg/dl) occurs in normal adults a few hours after fasting has
begun. However, the reduction in serum glucose ceases due to increased
gluconeogenesis in the liver. That occurs because of a decrease in insulin
concentration and a rise in glucagon and sympathetic activity (3). In
children aged one years to nine years, fasting for a 24-hour period has caused a
decrease in the blood glucose to half of the baseline figure for normal children
of that age group. In 22% of these children, blood glucose has fallen below 40
mg/dl (4). Few studies have shown the effect of Ramadan fasting on serum glucose
(5-9). One study has shown a slight decrease in serum glucose in the first days
of Ramadan, followed by normalization by the twentieth day and a slight rise by
the twenty-ninth day of Ramadan (6). The lowest serum glucose level in this
study was 63 mg/dl. Others have shown a mild increase (7) or variation in serum
glucose concentration (8,9), but all of them fell within physiological limits
(6). From the foregoing studies, one may assume that the stores of glycogen,
along with some degree of gluconeogenesis, maintain normal limits of serum
glucose when a fast follows a large pre-dawn meal. However, slight changes in
serum glucose may occur in individuals depending upon food habits and individual
differences in metabolism and energy regulation.
Body weight during Ramadan fasting
(a) In normal subjects:
Weight losses of 1.7 kg. (10), 1.8
kg. (11), 2.0 kg.
(12) and 3.8 kg
(13) have been reported in normal weight
individuals after they have fasted for the month of Ramadan. In one study that
was over-represented by females, no change in body weight was seen (14). It has
also been reported that overweight persons lose more weight than normal or
underweight subjects (12).
(b) In diabetics:
A review of literature shows
controversy about weight changes in diabetics during Ramadan. (6,15-24). In one
group of studies, patients had an increase in their weight (17,21). In another
group, there were no change (15,19,22,23)
or a decrease (6,16,18,20,24) in body
weight. While no food or drink is consumed between dawn and sunset during
the month of Ramadan, there is no restriction on the amount or type of food
consumed at night (23,25). Furthermore, most diabetics reduce their daily
activities (15,23) during this period in fear of hypoglycemia. These factors may
result in not only a lack of weight loss, but also a weight gain in such
patients (26). (See later discussion about nutrition and physical activity.)
Blood glucose variations during Ramadan fasting in diabetics
Most patients show no significant
change in their glucose control (3,23,24,27). In some patients, serum glucose
concentration may fall or rise (28-30). This variation may be due to the amount
or type of food consumption, regularity of taking medications, engorging after
the fast is broken, or decreased physical activities. In most cases, no episode
of acute complications (hypoglycemic or hyperglycemic types) occurs in patients
under medical management (9,15,16,22), And only a few cases of biochemical
hypoglycemia without clinical hazards have been reported (17,19,25).
Other parameters of diabetes control during Ramadan fasting
In general, HbAIC values show no
change or even improvement during Ramadan (15-18,20,22,23,25,27,28,32). Only two
studies have reported slight increases in glycated hemoglobin levels (19,31).
However, one report has emphasized the same increase in non-fasting patients as
fasting patients (31), and the other has shown a return to initial levels
immediately after the month of Ramadan (19).
The amount of fructosamine (17,22,24,30,32), insulin,
C-peptide (23,30) also has been reported to have no
significant change before and during Ramadan fasting.
Energy intake and serum lipid variables during Ramadan fasting in diabetics
The amount of Energy (calorie) intake
have been reported in some of the literature, indicating a decrease in energy
Most patients with non-insulin
dependent diabetes mellitus (NIDDM, diabetes type II) and insulin dependent
diabetes mellitus (IDDM, diabetes type I) show no change or a slight decrease in
concentrations of total cholesterol and triglyceride (15-19,27,28,32). Increase
in total cholesterol levels during Ramadan seldom occurs (23). As in healthy
persons (33-36), few studies have reported increases in high-density-lipoprotein
(HDL) cholesterol in diabetics during Ramadan (18,19,27). One report indicates
an increase in low-density-lipoprotein (LDL) cholesterol and a decrease in HDL-cholesterol
(28). Until there is a standardization of diabetes Ramadan research in three
fundamental factors -- the Three D Triangle of drug regimens, diet control and
daily activity -- the benefits or hazards of Ramadan fasting on diabetics serum
lipids is unclear.
Other biological parameters during Ramadan fasting in
Serum creatinine, uric acid, blood
urea nitrogen, protein, albumin, alanine amino-transferase, aspartate amino-transferase
values do not show significant changes during the fasting period (15,17,32).
Slight non-significant increases in some biological parameters may be due to
dehydration and metabolic adaptation and have no clinical presentation.
FASTING GUIDELINES TO DIABETICS
During the last two decades, a better
understanding of pathophysiological 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
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
Patients with a history of diabetic
Pregnant diabetic patients;
Diabetic patients will inter-current infections;
Elderly patients with any degree of alertness problems;
Two or more episodes of hypoglycemia and/or hyperglycemia during Ramadan.
Allow fasting in:
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
EDUCATION OF THE DIABETICS BEFORE RAMADAN
NIDDM patients and IDDM patients who
insist on fasting should be given a few recommendations about fasting (16). They
should be forbidden from skipping meals, taking medication irregularly or
gorging after the fast is broken (26).
The principles of pre-Ramadan
considerations are (37):
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
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 foods contributes to the tendency towards hyperglycemia
and weight gain (21,23). It has been emphasized that Ramadan fasting benefits
appear only in patients who maintain their appropriate diets (24,38,39). Thus,
in order to optimize control, diabetics must be reminded to abstain from the
high-calorie and highly-refined foods prepared during this month (38).
II. Physical activity and Ramadan fasting:
Several studies indicate that light
to moderate regular exercise during Ramadan fasting is harmless for NIDDM
patients (15). It has been shown that fasting does not interfere with tolerance
to exercise (40). It should be impressed upon diabetic patients that it is
necessary to continue their usual physical activity especially during
non-fasting periods (41)
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 (16). 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 (16).
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 (25).
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 (3). 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 (31).
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 weights 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 (25).
POST-RAMADAN SUPERVISION OF FASTING DIABETICS
After the month of Ramadan ends, the
patients therapeutic regimen should be changed back to its previous schedule.
Patients should also be required to get an overall education about the impact of
fasting on their physiology (37).
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
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 (42).
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 (43), and this should be considered in all Ramadan fasting research
Pages : 1