Dr Ahmad Moolla, Dr Nadia Khalid and Dr Tahseen Chowdhury look at some of the key considerations when managing fasting patients with Type 2 diabetes during Ramadan:

What is Ramadan?
Ramadan is the month within the Islamic year inwhich Muslims observe daily fasts. Fasting is one of the five major tenets of the Islamic faith that also include the proclamation of faith in one God, giving regular charity, performing the Hajj pilgrimage and establishing regular prayer. As the Islamic calendar follows the lunar cycle, Ramadan occurs approximately 11 days earlier each year and so the season in which it falls varies on a periodic basis.

What does Ramadan involve?
During daylight hours from sunrise to sunset, Muslims observe a strict fast, neither eating foods nor drinking "uids. In the summer months, fasting can be up to 18 hours long, while in the winter months they last around 12 hours. Muslims must also refrain from smoking, intimate relations and exert a greater effort to focus on good manners, inner re"ection and patience with others. Attention is also paid to the five daily prayers and many Muslims will attend special congregational prayers at their local mosque that continue into the late evening after the break of fast. As a result, Ramadan is physically and spiritually arduous, particularly with the longer duration of fasts seen in Northern Europe. 
 
riskstratificationWhat risks are associated with diabetes and fasting?
The major risks of fasting are of hypoglycaemia, hyperglycaemia and dehydration.1 Patients who are on insulin or oral hypoglycaemic therapy have a significant risk of hypoglycaemia due to changes to their meal routines. Larger meals as well as fried and sugary food are more often eaten during Ramadan which can cause greater variability in blood glucose levels and deterioration in glucose control. These risks and that of dehydration in particular are greatly increased in the summer months when fasts are longest.

Are there health benefits to be gained from fasting?
The 2010 Ramadan Education and Awareness in Diabetes (READ)2 study suggested that patients with diabetes who underwent a Ramadan-focused structured educational programme that included guidance on physical activity, meal planning, glucose monitoring and hypoglycaemia, achieved weight loss and a reduction in hypoglycaemic events in comparison with those who did not receive this guidance. Furthermore, these health benefits were sustained throughout the year with HbA1c unchanged in this group, compared with an increase in HbA1c in those who received no support. Patients who did not receive guidance in fact gained weight during Ramadan which is likely to be a re"ection of both the type of food and size of meals eaten.

Exemption from fasting
There is clear dispensation in Islam to exempt a person from fasting where it would adversely affect their health. As such, there is consensus among Islamic scholars to exempt patients with diabetes from fasting. Nonetheless, as diabetic patients often do not feel physically unwell many will choose to fast, irrespective of medical advice, due to feelings of obligation or guilt. One epidemiological study showed that up to 79% of patients with type 2 diabetes chose to fast during Ramadan.3

Assessment and management
As minimum, all patients with diabetes who are planning on fasting should have a consultation with a healthcare professional – either a diabetic specialist nurse, GP or diabetes physician. Patients should be stratified into high, medium or low risk groups (see Table 1) and be given appropriate guidance to help them make the personal choice of whether to fast. Figure 1 summarises expert consensus on how to approach the management of oral therapies for patients with type 2 diabetes during Ramadan. 
ramadanfastingmanagement
 4focusareas

Key Points
1 All patients with diabetes who are planning on fasting should as minimum, have a consulatation with a healtcare professional - either a diabetic specialist nurse, GP or diabetes physician - to discuss their management during Ramadan.

2 Patients should be advised regarding the signs and symptoms of hypoglycaernia and hyperglycaernia and be given instructions on what to do if these occur.

3 Regular blood glucose monitoring is essential particularly during the summer months when fasts are at their longest to prevent hypoglycaernia.

4 Meal planning and dietary advice ideally with dietician input to ensure a healthy balanced diet is continued during Ramadan, will help to reduce variability in blood glucose and help reduce complications.

5 Patients should maintain their usual physical activity during Ramadan though heavy or rigorous exercise is better avoided.

6 Well targeted educational programmes via a mulitdisciplinary approach will help ensure patients are aware of the imact that fasting may have on their immediate and longer term health and may assist patients in better managing their diabetes.

 

Authors
Dr Ahmad Moolla Honorary Clinical Lecturer, Faculty of Medicine, Imperial College London
Dr Nadia Khalid GP Specialist Trainee, London
Dr Tahseen Chowdhury Consultant in Diabetes, Department of Diabetes and Metabolism, Royal London Hospital 

References for further reading:
1 Hui E, Bravis V,fiHassanein M, et al. BMJ.fi2010;340:c3053
2 Bravis V, Hui E,fiSalih S, et al. Diabet. Med. 2010;27,327–331
3 Salti I, Bénard E,fiDetournay B, etfial. Diabetes Carefi2004;27:2306–2311.
4 Al-Arouj M, et al.fiDiabetes Care 2005;28:2305-11
5 The Facts About Fasting During Ramadan, Silver Star 2012,
6 Ramadan and diabetes, Diabetes UK, September 2004.
7 www.diabetes.org.uk/Documents/Languages/English/Ramadan_Eng.pdf (last accessed 03 June 2013)