Fasting during the holy month of Ramadan is one of the five pillars of Islam and commemorates the time when the Holy Quran was revealed to Muhhammad. The month-long (29-30 day) fast is obligatory for all healthy Muslims who have reached puberty. Followers must refrain from eating and drinking between dawn and sunset, and must abstain from using oral medications, sexual activity and smoking.
The timing of Ramadan is based on the lunar calendar (355 days per lunar year), which is shorter than the Gregorian (Western) calendar, and Ramadan occurs 10–11 days earlier each every year. This means that the duration of daylight fasting varies according to the time of year in which Ramadan falls. In some parts of the world, daylight can be as long as 20 hours in the peak of summer.
Ramadan is widely observed across the world. Followers must refrain from eating and drinking between dawn and sunset, and must also abstain from using oral medications, sexual activity and smoking. It is believed that spiritual rewards for good deeds are multiplied during Ramadan, and there is an intense desire to participate in fasting, even among those who could seek exemption, such as the elderly, children, the disabled, and pregnant women.
Many Muslims, even those who could seek exemption, have an intense desire to participate in fasting during Ramadan.
Fasting is mandatory for all Muslim adults, with certain groups exempted, such as those with an illness – this may include some individuals with diabetes. Because of the metabolic nature of the disease, people with diabetes are at particular risk of complications from marked changes in food and fluid intake. Potential health hazards include low blood glucose (hypoglycaemia), high blood glucose (hyperglycaemia), dehydration and acute metabolic complications such as diabetic ketoacidosis (DKA).
Estimates suggest that there are 150 million Muslims with diabetes worldwide. Despite being exempt, many people with diabetes participate in fasting during Ramadan. Therefore, Ramadan has a major impact on the management of diabetes in the Muslim population.
Fasting and diabetes
It is 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. A cornerstone of managing diabetes during Ramadan is patient education, which should include information on risks, glucose monitoring, nutrition, exercise and medication.
Studies have shown that pre-Ramadan counselling reduces the episodes of low blood glucose. Pre-Ramadan education provides a platform to remind people with diabetes about the importance of diet and exercise, and that regular glucose monitoring is essential to avoid complications, while reassuring them that this does not invalidate the fast.
Fasting during Ramadan may provide enduring benefits. Indeed, Ramadan can provide an opportunity for a better lifestyle, facilitating weight loss and stopping smoking. For people with diabetes who choose to fast, Ramadan may help to strengthen the therapeutic alliance between patient and physician, and may provide an opportunity to improve diabetes management, with a focus on self-care and the regulation of medication and meal timing.
What to know and do?
Know your risk: 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 measurement and insulin injection 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.
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-ul-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
Divide daily calories between suhoor and iftar, plus 1-2 snacks if necessary
Ensure meals are well balanced: 45-50% carbohydrate 20-30% protein <35% fat
Include plenty of fruit, vegetables and salads
Minimise foods that are high in saturated fats (ghee, samosas, pakoras)
Use small amounts of oil when cooking (olive, rapeseed)
Stay hydrated between sunset and sunrise by drinking water or other non-sweetened beverages. Avoid caffeinated, sweetened drinks and sugary desserts
Include low glycaemic index, high fibre foods that release energy slowly before and after fasting (granary bread, beans, rice)
Healthy recipes for Ramadan
Click on the images below to download the preparation instructions. The original ingredients have been modified to align with healthy nutritional recommendations so we recommend using the ingredients as shown in the images.
Suhoor (pre-dawn meal)
IFTAR (evening meal)
IDF-DAR Practical Guidelines
With the global prevalence of diabetes continuing to increase, and the number of fasting Muslims set to rise, the importance of effective guidelines for the management of diabetes during Ramadan fasting is clear. The IDF-DAR Practical Guidelines provide healthcare professionals with both background and practical information, as well as management recommendations to optimise the care delivered to people with diabetes who plan to fast during Ramadan.