Those exempt from fasting include children younger than 12 years; people who are ill; travelers; and menstruating, pregnant, or nursing women.

Healthy Muslims are obliged to abstain from all food, drink, and oral medications from dawn to sunset throughout the month. Most people eat two major meals a day—suhoor (meal before dawn) and iftar (meal after sunset). Many people also have snacks well into the night, which are often foods that are high in fat and have a high glycemic index.

There can be significant glycemic variability of blood sugars during Ramadan, with studies showing up to a 7.5-fold rise in hyperglycemia and 5-fold rise in hypoglycemia in patients with type 2 diabetes.[1,2]

Another important consideration is that certain Muslims may also follow an up to 3-day-long Sugar Feast (Şeker Bayramı or Eid al-Fitr) at the end of the holy month, which marks the end of Ramadan. This is a celebratory period where gifts are exchanged and there is increased consumption of high-carb celebratory treats. Many Muslims will indulge in communal feasting, with family and friends eating together from a single large platter. This may cause one to lose judgement of individual portion sizes, leading to glycemic surges.

I strongly encourage patients to practice portion control, ensure hydration, restart their pre-Ramadan diabetes medication regimen, and monitor blood sugars closely during the time of the Sugar Feast.

It is important to note that Muslims who did not fast may also participate in the Sugar Feast. Therefore, the above recommendations need to be discussed even with those who say that they do not plan to fast during Ramadan.

Islamic scholars advise Muslims to ask their HCPs about their ability to fast safely during Ramadan; therefore, it is very important that all HCPs have a working knowledge of Ramadan-specific counseling of patients with diabetes.

How Do You Know Who Will Be Fasting?
Ask whether your patient plans on fasting during Ramadan. Being a non-Muslim myself, I have seen that many patients do not volunteer this information because they might feel that I wouldn’t understand their practices.

If they answer in the affirmative, it is okay to ask how many days they intend to fast. Often, this will lead them to ask me if I feel that it is safe for them to do so. Asking patients specifically about their plans during Ramadan helps to create an environment where they feel that all stakeholders are invested in ensuring healthy fasting.

Data from the CREED study[3] indicate that about 95% of Muslims with type 2 diabetes fast for at least 15 days during Ramadan. However, only about 64% fast for all days of the month, while 31% fast for less than 30 days. Hence, there is significant risk for intraday and interday glycemic variability on the basis of whether the patient is fasting or not and what medication adjustments have been made.

Is Your Patient Too Sick to Fast?
The Koran specifically exempts the sick from the duty of fasting, especially if fasting might lead to harmful consequences for the individual. Patients with diabetes can fall under this category, and it is strongly recommended that physicians do a risk preassessment for the patient at least 3-4 weeks before the start of Ramadan.

Very high-risk patients include those with poorly controlled type 1 diabetes, advanced renal disease, cognitive dysfunction, or recent history of hypo/hyperglycemic emergencies.

High-risk patients include those with poorly controlled type 2 diabetes or who are on multiple daily injections of insulin.

Moderate/low-risk patients are those with well-controlled type 2 diabetes who are on oral agents and/or basal insulin therapy.

HCPs are recommended to advise that very high-risk patients must not fast, high-risk patients should not fast, and moderate/low-risk patients can fast with medical advice.

How to Safely Guide Your Patients Through Ramadan