Fasting with diabetes can lead to complications that include:

• Low blood glucose (hypoglycaemia)
• High blood glucose (hyperglycaemia)
• Dehydration
• Diabetic ketoacidosis (DKA), in people with type 1 diabetes

It is therefore important that the decision about whether to fast is made on an individual basis in consultation with a healthcare provider, taking into account the severity of illness and the level of risk involved. 

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Tips for a healthy Ramadan with diabetes

Know your risk before you decide to fast

As per the Holy Quran, there are groups of people who might make themselves ill by fasting. Based on medical and religious advice, it is recommended to visit your doctor 6-8 weeks before Ramadan to understand your risk category before deciding to fast. If your doctor advises not to fast, you will get the same Thawab (reward).

Check your blood glucose regularly

Blood glucose monitoring and insulin injections do not break the fast and are important. They are your window to know your blood glucose levels and manage your diabetes. Changes in eating habits during Ramadan may affect your blood glucose and therefore it is important check blood glucose levels regularly.

• People at very high risk (even if not fasting) should check blood glucose levels 3-4 times a day
• People at moderate or low risk should check blood glucose levels 1-2 times a day

Medication adjustments during fasting

Talk to your doctor about the adjustments required to the dose, timing or type of medication to reduce the risk of low blood sugar.

It is important to know that measuring your blood glucose and injecting insulin will not break your fast.

When to break the fast?

All people with diabetes should break the fast if:

• Blood glucose is lower than 70 mg/dl (3.9 m mol/L). Re-check within one hour if blood glucose is in the range 70-90 mg/dl (50- 3.9 m mol/L)
• Blood glucose is higher than 300 mg/dl (16.6 m mol/L)*
• Symptoms of hypoglycemia, hyperglycemia, dehydration or acute illness occur

Exercising during Ramadan

Perform regular light-to moderate exercise. Rigorous exercise is not recommended during fasting because of the increased risk of low blood glucose and/or dehydration. Physical exertions involved in Tarawih prayers, such as bowing, kneeling and rising, should be considered part of your daily exercise activities.

When the month of Ramadan ends

Avoid over-eating (especially sweets) during Eid-al-Fitr, as it may lead to high blood glucose. Visit your doctor to obtain guidance on changing the medication back to the previous schedule.

Dietary advice for people with diabetes during fasting 

Snacks		Divide daily calories between Suhoor and Iftar, plus 1-2 snacks if necessary
Carbohydrates		Ensure meals are well balanced: 45-50% carbohydrate 20-30% protein <35% fat
Vegetables		Include plenty of fruit, vegetables and salads
Saturated fat		Minimise foods that are high in saturated fats (ghee, samosas, pakoras)
Oil		Use small amounts of oil when cooking (olive, rapeseed)
Drinks		Stay hydrated at or between the two main meals by drinking water or other non-sweetened beverages.  Avoid caffeinated, sweetened drinks and sugary desserts
Bread		Include low glycaemic index, high fibre foods that release energy slowly before and after fasting  (granary bread, beans, rice)

COVID-19 and fasting with diabetes

The currently available epidemiological data shows that people who fast do not report higher rates of infections or hospitalization. There is therefore no evidence that fasting could lead to reduced immunity and higher risk for infection.

However, people with diabetes and complications, such as renal impairment or foot problems, are at high risker of infections. It is therefore important that they follow medical advice and do not fast to avoid increasing their risk of contracting COVID-19.

• General advice, Diabetes, Ramadan and COVID-19 (Diabetes Ramadan Alliance)