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| Ramadan Fasting and Diabetes
Mellitus Fereidoun Azizi, MD, and Behnam Siahkolah, MD Endocrine Research Center, Shaheed Beheshti University of Medical Sciences, Tehran, I.R. Iran Abstract: INTRODUCTION Several of the world's great religions recommend a period of fasting or abstinence from certain foods. Of these, the Islamic fast during the Muslim month of Ramadan is strictly observed every year. Islam specifically outlines one full month of intermittent fasting. The experience of fasting is intended to teach Muslims self-discipline and self-restraint and remind them of the plight of the impoverished. Muslims observing the fast are required to abstain not only from eating and drinking, but also from consuming oral medications and intravenous nutritional fluids.
The month of Ramadan contains 28
days to 30 days. The dates of observance differ each year because Ramadan
is set to a lunar calendar. Fasting extends each day from dawn until
sunset, a period which varies by geographical location and season. In
summer months and northern latitudes, the fast can last up to 18 hours or
more. Islam recommends that fasting Muslims eat a meal before dawn, called
"sahur." Individuals are exempt from Ramadan fasting if they are
suffering from an illness that could be adversely affected by fasting.
They are allowed to restrain from fasting for one day to all 30
days,depending on the condition of their illness. People diagnosed with
diabetes fall into this category and are exempt from the fasting
requirement, but they are often loathe to accept this concession.
Physicians working in Muslims countries and communities commonly
face the difficult task of advising diabetic patients whether it is safe
to fast, as well as recommending the dietary and drug regimens diabetics
should follow if they decide to fast. The lack of adequate literature on
this subject makes it difficult to answer these questions. To judge
correctly whether to grant medical permission to fast to a diabetic
patient, it is essential physicians have an appreciation of the effect of
Ramadan fasting on the pathophysiology of diabetes mellitus. In this
article, we first review principles of carbohydrate metabolism and
alterations of certain biochemical variables in diabetics observing
Ramadan fasting. We then overview current medical recommendations that
allow certain diabetic patients to fast and outline terms for diabetic
patients, particularly IDDM patients, who should not fast but insist on
fasting. THE PHYSIOLOGICAL STATE OF DIABETICS
DURING RAMADAN Carbohydrate metabolism during Ramadan
fasting in healthy persons
The effect of experimental short-term fasting on carbohydrate
metabolism has been extensively studied (1,2). It has been uniformly found
that a slight decrease in serum glucose to 3.3 mmol to 3.9 mmol (60 mg/dl
to 70 mg/dl)occurs in normal adults a few hours after fasting has begun.
However, the reduction in serum glucose ceases due to increased
gluconeogenesis in the liver. That occurs because of a decrease in insulin
concentration and a rise in glucagon and sympathetic activity (3).
In children aged one years to nine years, fasting for a 24-hour
period has caused a decrease in the blood glucose to half of the baseline
figure for normal children of that age group. In 22% of these children,
blood glucose has fallen below 40 mg/dl (4). Few studies have shown the
effect of Ramadan fasting on serum glucose (5-9). One study has shown a
slight decrease in serum glucose in the first days of Ramadan, followed by
normalization by the twentieth day and a slight rise by the twenty-ninth
day of Ramadan (6). The lowest serum glucose level in this study was 63
mg/dl. Others have shown a mild increase (7) or variation in serum glucose
concentration (8,9), but all of them fell within physiological limits (6).
From the foregoing studies, one may assume that the stores of glycogen,
along with some degree of gluconeogenesis, maintain normal limits of serum
glucose when a fast follows a large pre-dawn meal. However, slight changes
in serum glucose may occur in individuals depending upon food habits and
individual differences in metabolism and energy regulation. Body weight during Ramadan fasting (a) In normal subjects: (b) In diabetics: Blood glucose variations during Ramadan
fasting in diabetics
Most patients show no significant change in their glucose control
(3,23,24,27). In some patients, serum glucose concentration may fall or
rise (28-30). This variation may be due to the amount or type of food
consumption, regularity of taking medications, engorging after the fast is
broken, or decreased physical activities. In most cases, no episode of
acute complications (hypoglycemic or hyperglycemic types) occurs in
patients under medical management (9,15,16,22), And only a few cases of
biochemical hypoglycemia without clinical hazards have been reported
(17,19,25). Other parameters of diabetes control
during Ramadan fasting
In general, HbAIC values show no change or even improvement during
Ramadan (15-18,20,22,23,25,27,28,32). Only two studies have reported
slight increases in glycated hemoglobin levels(19,31). However, one report
has emphasized the same increase in non-fasting patients as fasting
patients (31), and the other has shown a return to initial levels
immediately after the month of Ramadan (19).
The amount of fructosamine (17,22,24,30,32), insulin,
C-peptide(23,30) also has been reported to have no significant change
before and during Ramadan fasting. Energy intake and serum lipid variables
during Ramadan fasting in diabetics
The amount of Energy (calorie) intake have been reported in some of
the literature, indicating a decrease in energy intake (24,28).
Most patients with non-insulin dependent diabtes mellitus (NIDDM,
diabetes type II) and insulin dependent diabetes mellitus (IDDM, diabetes
type I) show no change or a slight decrease in concentrations of total
cholesterol and triglyceride (15-19,27,28,32). Increase in total
cholesterol levels during Ramadan seldom occurs (23). As in healthy
persons (33-36), few studies have reported increases in
high-density-lipoprotein (HDL) cholesterol in diabetics during Ramadan
(18,19,27). One report indicates an increase in low-density-lipoprotein (LDL)
cholesterol and a decrease in HDL-cholesterol (28). Until there is a
standardization of diabetes Ramadan research in three fundamental factors
-- the Three D Triangle of drug regimens, diet control and daily activity
-- the benefits or hazards of Ramadan fasting on diabetics serum lipids is
unclear. Other biological parameters during
Ramadan fasting in diabetics
Serum creatinine, uric acid, blood urea nitrogen, protein, albumin,
alanine amino-transferase, aspartate amino-transferase values do not show
significant changes during the fasting period (15,17,32). Slight
non-significant increases in some biological parameters may be due to
dehydration and metabolic adaptation and have no clinical presentation. FASTING GUIDELINES TO DIABETICS
During the last two decades, a better understanding of
pathophysiological changes during Ramadan fasting in diabetic patients has
provided a few guidelines on how to advise diabetics who want to fast.
Physicians working with Muslim diabetics should employ certain criteria to
advise their patients regarding the safety of Ramadan fasting. The following criteria should be helpful in
making such a decision (20,37): Forbid fasting in:
Allow fasting in:
Encourage fasting in:
EDUCATION OF THE DIABETICS BEFORE
RAMADAN
NIDDM patients and IDDM patients who insist on fasting should be
given a few recommendations about fasting (16). They should be forbidden
from skipping meals, taking medication irregularly or gorging after the
fast is broken (26).
The principles of pre-Ramadan considerations are (37): (a) assessment of physical well being; (b) assessment of metabolic control; (c) adjustment of the diet protocol for Ramadan fasting; (d) adjustment of the drug regimen e.g. change long-acting hypoglycemic drugs to short-acting drugs to prevent hypoglycemia); (e) encouragement of continued proper physical activity; (f) recognition of warning symptoms of
dehydration, hypoglycemia and other possible complications. RECOMMENDATIONS DURING RAMADAN FASTING I. Nutrition and Ramadan fasting: II. Physical activity and Ramadan fasting: III. Drug regimens for IDDM patients:
1. Three-dose insulin regimen: two doses before meals (sunset and
Dawn) of short-acting insulin and one dose in the late evening of
intermediate-acting insulin (16)
2. Two-dose insulin regimen: Evening insulin combined with
short-acting and medium-acting insulin equivalent to the previous morning
dosage, and a pre-dawn insulin consisting only of a regular dosage of
0.1-0.2 unit/kg (25).
Home blood glucose monitoring should be performed just before the
sunset meal and three hours afterwards. It should also be performed before
the pre-dawn meal to adjust the insulin dose and prevent any hypoglycemia
and post-prandial hyperglycemia following over-eating. IV.
Drug regimens for NIDDM patients:
The authors of the largest series of patients treated with
glibenclamide during Ramadan recommended that diabetics switch the morning
dose (together with any mid-day dose) of this drug with the dosage taken
at sunset (31). V. Other health tips for reduction of
complications: 1. Implementation of the 3D Triangle of
Ramadan -- drug regimen adjustment, diet control and daily activity -- as
the three pillars for more successful fasting during Ramadan. 2. Diabetic home management that consists
of:
3. Education about warning symptoms of
dehydration, hypoglycemia and hyperglycemia. 4. Education about breaking fast as soon as
any complication or new harmful condition occurs. 5. Immediate medical help for diabetics who
need medical help quickly, rather than waiting for medial assistance the
next day. 6. Further attention on fasting during the
summer season and geographical areas with long fasting hours. VI.
IDDM children and Ramadan fasting: POST-RAMADAN SUPERVISION OF FASTING
DIABETICS
After the month of Ramadan ends, the patients therapeutic regimen
should be changed back to its previous schedule. Patients should also be
required to get an overall education about the impact of fasting on their
physiology (37). THE RESEARCH METHODOLOGY ON DIABETICS
DURING RAMADAN
From a methodological point of view, few research papers on Ramadan
fasting are relevant because of the absence of control periods before
Ramadan and afterwards, the absence of measurements during each week of
Ramadan, a lack of attention to dietary habits, food composition, food
value, caloric control, weight changes and the importance of the schedule
during circadian periods.
It is recommended that all these factors should be taken into
consideration and that all intervening and confounding variables should be
under control. It is clear that more work should be done on Ramadan
fasting to evaluate physiological and pathological changes with proper
research methods (42).
Fasting during the entire month of Ramadan is reserved usually for
healthy Muslims. However, many diabetic patients are allowed to fast
periodically during Ramadan. The magnitude of periodic total fasting
effect on blood glucose and hepatic glucagon depends on the number of
fasting days (43), and this should be considered in all Ramadan fasting
research activities. CONCLUSION The bulk of literature indicates that fasting in Ramadan is safe for the majority of diabetics patients with proper education and diabetic management. Most NIDDM patients can fast safely during Ramadan. Occasional IDDM patients who insist on fasting during Ramadan can also fast if they are carefully managed. Strict attention to diet control, daily activity and drug regimen adjustment is essential for successful Ramadan fasting.
To shed more light on
pathophysiological changes in Ramadan fasting, in particular in Muslims
diabetics, it is recommended that a multicentric international controlled
clinical trial be employed to assess the effect of differences in gender,
races, physical activities, food habits, sleep patterns and other
important variables on physiologic and pathologic conditions during
Ramadan fasting. Address correspondence to: REFERENCES (1) Cahill GF Jr. Starvation in men. N Engl
J Med .1970; 282:668-675.
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