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Managing hypoglycaemia risk during Ramadan

21st April 2021

Awareness among healthcare professionals and the importance of education and discussion with patients were key points in a survey of issues around hypoglycaemia and how to fast safely during Ramadan at the South Asian Health Foundation (SAHF) and Diabetes and Ramadan (DAR) International Alliance Annual Diabetes in Ramadan Conference in March.

Fasting from sunrise to sunset during the holy month of Ramadan, which started last week, is one of the five pillars of Islam. A decrease in food intake is a well-known risk factor for hypoglycaemia, and yet – despite the fact that having a medical condition such as diabetes exempts you from this religious observation – up to 79% of Muslims with diabetes still fast for at least 15 days.

In his presentation to the conference, Dr Mohammad Alhadj Ali, clinical lecturer in diabetes and endocrinology at Cardiff University School of Medicine, highlighted a line in a verse from the Qur’an about exemption, for the benefit of healthcare professionals who are non-Muslims: ‘… and whoever is ill or on a journey – then an equal number of other days, Allah intends for you ease and does not intend for you hardship…’.

For those who choose to fast, the period from sunrise to sunset can be up to 18 hours in some countries, which will in turn increase the risk of hypoglycaemia. Other risks to people with diabetes are hyperglycaemia, dehydration and acute metabolic complications.

Such problems are not restricted to people with type 1 diabetes. According to figures from one of the studies Dr Ali presented (the EPIDIAR study), rates of severe hypoglycaemia among type 1 patients increased 4.7 fold during Ramadan; among patients with type 2 diabetes, there was a 7.5-fold increase.

Dr Ali highlighted another complicating issue; that the symptoms of hypoglycaemia, such as being hungry, dizzy, shaky, confused etc, can be felt by people without diabetes when they begin fasting, so vigilance and frequent blood glucose monitoring is required to recognise hypoglycaemia. The complications of severe hypos are rare but life-threatening, such as convulsions, loss of consciousness and inability to swallow.

The current guidance is that patients with type 1 diabetes who have a history of recurrent hypos, hypo unawareness, poor control, brittle diabetes, non-compliance with medical treatment, or who are unwilling or unable to monitor and control blood glucose, are to be considered very high risk and should not fast.

So how should healthcare professionals prepare patients? It should start with a pre-Ramadan assessment one to two months beforehand to quantify the risks for that patient, along with education and awareness around what will need to change during Ramadan. This includes modifying meal plans to help glycaemic control, adjustments to medication, blood glucose monitoring (there are recommended times and it should be at least six times during the day, starting at dawn, with levels checked at any time if hypoglycaemia is recognised), advice around exercise and when to break the fast (this should be done immediately if hypoglycaemia occurs, even if it’s minutes before sunset, and also if blood glucose reaches less than 3.9 mmol/l in the first few hours after the start of the fast, especially if insulin, sulphonylureas or a combination of oral antidiabetic drugs are taken with the pre-dawn meal).

Detailed guidance on all of this is available in the Diabetes and Ramadan Practical Guidelines, published in January 2021.

Dr Ali also mentioned the Ramadan Education and Awareness in Diabetes (READ) Programme, which can be done in the weeks before fasting begins and covers subjects such as blood glucose monitoring and meal planning. A study has shown the READ Programme to result in a 44% reduction in hypoglycaemia compared to baseline.

For more on the issues raised here, see our course Diabetes and Ramadan.

For more on prevention and management of hypoglycaemia, see our course Hypoglycaemia.

The views expressed in this article are those of the author, Dr Eleanor D Kennedy.