To ensure people with diabetes are fasting safely, they should seek the advice of a doctor ahead of Ramadan, and throughout the fasting period, they will need to be vigilant in checking their blood sugar levels, and will need to know the health risks and warning signs to watch for, advises an expert from Imperial College London Diabetes Centre (ICLDC), a Mubadala Health partner.
Dr Farhana Bin Lootah, an internal medical consultant at ICLDC, explains that the four main risks of fasting for a person with diabetes are hypoglycaemia (low blood sugar), hyperglycaemia (high blood sugar), dehydration, and diabetic ketoacidosis (DKA), which is a serious complication of diabetes involving very high sugar levels together with the formation of excess acids in the blood.
In general, people with type 1 diabetes are exempt from fasting, although it is possible for this category to fast healthily in certain cases, while some people with type 2 diabetes will also be advised not to fast. Dr Lootah explains that when patients seek advice, their doctor will consider their type of diabetes (type 1, type 2 or gestational diabetes), their medical history including kidney health, and whether their blood sugar has been well-controlled for a significant period, among other factors.
Once cleared for fasting, patients will need to check their blood sugar several times a day, Dr Lootah says, as the levels can fluctuate significantly when the body enters into a fasting state and after breaking the fast, particularly if the iftar meal is a large one.
“Your body enters into a fasting state around eight hours after your last meal, and it will initially use stored sources of glucose, which can increase the risk of low blood sugar on some medications and/or insulin,” she explains.
Self-monitoring of glucose levels is essential and approved both in religious and medical contexts. “Religious scholars agree that taking blood samples either by ﬁnger-pricking or by a needle from arm veins to check blood-sugar levels does not invalidate the fast, and doctors agree it is important to perform the tests as they help patients fast safely,” says Dr Lootah.
Suggested timings for blood-glucose monitoring
Dr Lootah says that the recommended frequency of blood tests depends on the level of diabetes control and which form of diabetes is present. In general terms, though, a minimum of one to two tests per day is recommended for people with type 2 diabetes, and a minimum of two to three tests for type 1.
ICLDC suggests the following potential timetable and targets:
Before suhoor: blood glucose targets should be 120-140mg/dl
Mid-morning: blood glucose targets should be 140-180mg/dl
Midday: blood glucose targets should be 120-180mg/dl
Before iftar: blood glucose targets should not be below 70mg/dl
2 hours after iftar: blood glucose targets should not be above 180mg/dl
At any time when there are symptoms suggestive of low blood sugar or high blood sugar or when feeling unwell
Dr Lootah adds that patients should be prepared to immediately break their fast if they have any of the following signs:
- Blood sugar level of less than 70 mg/dl
- Blood sugar level of more than 300 mg/dl
- Symptoms of low blood sugar (for example, feeling dizzy, sweaty or shaky, blurred vision, confusion or inability to think clearly, loss of consciousness)
- Symptoms of acute illness (for example, vomiting or diarrhoea)
In addition to checking blood sugar levels, people with diabetes will need to drink plenty of water during non-fasting hours to avoid the increased risk of dehydration, Dr Lootah advises.
“In short, with appropriate planning and monitoring, and by enlisting the help of a medical expert, a person with diabetes will be far better equipped to handle the unique set of challenges he or she faces during Ramadan,” Dr Lootah says.