Key terms include:
- Sehri/Suhoor - the pre-dawn meal before starting your fast.
- Iftar - the meal you break your fast with at sunset
Thank you to our friends Dr. Mohammed Seyam and Noor Al-Ramahi for sharing their clinical and academic perspectives in addition to their personal insights on Ramadan with diabetes this month!
Ramadan is a month in the lunar calendar observed by Muslims all over the world by fasting from dawn until sunset. Like all things related to food, fasting is significantly more complicated when you live with type 1 diabetes. Although there are medical exemptions from fasting for people with diabetes, the choice to participate in the month is one that many still make and being able to safely provide medical care during this month is especially important.
The shift in daily patterns, around both eating and sleeping during the month of Ramadan has a direct impact on the physiology of the body. The number of daylight hours varies across geographical locations, meaning the number of hours spent fasting varies, and the impact on people with diabetes will also vary. Put simply, in the absence of food and accompanying insulin, the body searches for new sources of energy. During periods of extended fasting, the liver does two things:
- Glycolysis - the breakdown of glycogen to produce glucose
- Glucogenesis - the breakdown of fat to create glucose from it.
Both of these lead to varying levels of insulin resistance. Every person with diabetes has their own unique physiology, and for some the process of glycolysis and gluconeogenesis and subsequent increased insulin resistance may begin after about 8 hours of fasting, for others it may be at 10, 12 or even 36 hours.
Another potential physiological impact as a result of the stress the body undergoes with a reduction in food and sleep is the increase in cortisol. Cortisol levels also have a side effect of insulin resistance that will vary across people with diabetes. This increase in insulin resistance is often the reason you will see a spike in blood sugars during Iftar - the meal to break the fast at sunset. A generous pre-bolus can be helpful to mitigate this spike, but it is also important to know that the body’s response to the act of fasting will be different across different people with diabetes.
It is important to understand that conducting a risk assessment and education are key to providing care for people with diabetes who participate in Ramadan. We know that managing blood sugars comes with a number of variables that can and cannot be controlled by people with diabetes and their care teams. The act of fasting for extended periods of times causes a disturbance in the body’s physiology and additional variables that are not usually accounted for. Monitoring for ketones and remembering the importance of hydration at both Suhoor and Iftar time is also important to help prevent dehydration. There are also physical and psychological benefits to fasting for people with diabetes, so providing access to informed medical advice along with technology like CGMs and automated insulin dosing can impact a person’s ability to safely participate in fasting during the month of Ramadan.
There are thankfully a great number of resources developed for healthcare providers to be able to guide their patients that want to try to participate in fasting during the month, and we have pulled together a few of our favorite here:
Clinical guidelines, resources and literature:
- Diabetes and Ramadan International Alliance
- IDF-DAR Practical Guidelines 2021
- ISPAD Clinical Practice Consensus Guidelines 2022: Ramadan and other religious fasting by young people with diabetes
- EASD e-Learning material about Diabetes and Ramadan
- Fasting guidelines for diabetic children and adolescents
- Ramadan and Diabetes: A Narrative Review and Practice Update
- Ramadan fasting and diabetes, latest evidence and technological advancements: 2021 update