Ramadan and Diabetes: A Narrative Review and Practice Update

Abstract

Fasting in the Islamic month of Ramadan is obligatory for all sane, healthy adult Muslims. The length of the day varies significantly in temperate regions-typically lasting ≥ 18 h during peak summer in the UK. The synodic nature of the Islamic calendar means that Ramadan migrates across all four seasons over an approximately 33-year cycle. Despite valid exemptions, there is an intense desire to fast during this month, even among those who are considered to be at high risk, including many individuals with diabetes mellitus. In this review we explore the current scientific and clinical evidence on fasting in patients with diabetes mellitus, focussing on type 2 diabetes mellitus and type 1 diabetes mellitus, with brief reviews on pregnancy, pancreatic diabetes, bariatric surgery, the elderly population and current practice guidelines. We also make recommendations on the management of diabetes patients during the month of Ramadan. Many patients admit to a do-it-yourself approach to diabetes mellitus management during Ramadan, largely due to an under-appreciation of the risks and implications of the rigors of fasting on their health. Part of the issue may also lie with a healthcare professional's perceived inability to grasp the religious sensitivities of Muslims in relation to disease management. Thus, the pre-Ramadan assessment is crucial to ensure a safe Ramadan experience. Diabetes patients can be risk-stratified from low, medium to high or very high risk during the pre-Ramadan assessment and counselled accordingly. Those who are assessed to be at high to very high risk are advised not to fast. The current COVID-19 pandemic upgrades those in the high-risk category to very high risk; hence a significant number of diabetes patients may fall under the penumbra of the 'not to fast' advisory. We recognize that fasting is a personal choice and if a person chooses to fast despite advice to the contrary, he/she should be adequately supported and monitored closely during Ramadan and for a brief period thereafter. Current advancements in insulin delivery and glucose monitoring technologies are useful adjuncts to strategies for supporting type 1 diabetes patients considered to be high risk as well as 'high-risk' type 2 patients manage their diabetes during Ramadan. Although there is a lack of formal trial data, there is sufficient evidence across the different classes of therapeutic hypoglycaemic agents in terms of safety and efficacy to enable informed decision-making and provide a breadth of therapeutic options for the patient and the healthcare professional, even if the professional advice is to abstain. Thus, Ramadan provides an excellent opportunity for patient engagement to discuss important aspects of management, to improve control in the short term during Ramadan and to help the observants understand that the metabolic gains achieved during Ramadan are also sustainable in the other months of the year by maintaining a dietary and behavioural discipline. The application of this understanding can potentially prevent long-term complications.

Keywords: COVID-19; Diabetes; Fasting; Iftaar; Ramadan; Suhoor; Technology; Type 1 diabetes; Type 2 diabetes.

Fig. 1

Physiology of glucose metabolism in the fed state

Fig. 2

Physiology of fasting in a healthy individual. β-OHB Beta-hydroxybutyrate

Fig. 3

Pathophysiology of fasting in diabetes patients. IF intermittent fasting, IR insulin resistance, T1DM type 1 diabetes mellitus, T2DM type 2 diabetes mellitus

Fig. 4

Mean 24-h continuous glucose monitoring (CGM) profiles derived from all patients with diabetes (n = 56) during Ramadan (Fasting) and non-Ramadan (Non-fasting) periods. The purple bars along the x-axis at the bottom of the graph depict periods when the difference between the two states is large and significant *Reprinted from Diabetes Metab, Vol 41, Lessan et al, Glucose excursions and glycaemic control during Ramadan fasting in diabetic patients: Insights from continuous glucose monitoring (CGM), pp28–36, Copyright (2015), with permission from Elsevier [17]

Fig. 5

Changes in cortisol circadian rhythm during Ramadan showing a shift in the cortisol profile on day 7 and a return to near baseline (non-Ramadan) values by day 21

Fig. 6

Pre-Ramadan assessment and plan of care