Reassessing the risks of Ramadan fasting

As Muslims around the world embark on a month of Ramadan fasting, for the latest episode in our series ‘The long and the short of it’, Professor Wasim Hanif and Dr Sarah Ali deliver a timely reminder of the importance of pre-Ramadan assessments for people with diabetes – and highlight recent developments that mean it may be time to reassess our approach to risk stratification.

Fasting during the month of Ramadan is one of the Five Pillars of Islam – the obligations Muslims must satisfy in order to live a good and responsible life. For those with diabetes, however, Ramadan fasting poses certain serious risks, including hyper- and hypoglycaemia, diabetic ketoacidosis (DKA), hyperosmolar hyperglycaemic state (HHS) and dehydration.

Nevertheless, despite the fact that the Qu’ran specifically exempts people with serious medical conditions such as diabetes, many people with diabetes still prefer to fast. Says Dr Sara Ali: “It’s important to remember that people who live with diabetes quite often do not perceive themselves as being ill or unwell. Indeed, that’s something we encourage as diabetes healthcare professionals. We encourage people to live a full life whilst having diabetes. So that means that when they come to the month of Ramadan, they want to be like other people, people who don’t have diabetes. They want to be able to fast.”

Steps healthcare professionals need to take to support their patients with diabetes who wish to fast during Ramadan – whether by empowering them to do so safely or, where appropriate, advising them against it – are briefly covered here, though the presenters recommend exploring this in more detail via the EASD’s eight e-Learning modules on the topic (several of which are presented by Professor Hanif himself).

What makes this film so compelling, though, is its reflection on recent developments that promise to have a profound effect on our approach to assessing the risks relating to Ramadan fasting for people with diabetes. Chief among these is the impact of new technologies, testing technologies in particular. Continuous glucose monitoring (CGM) has made it safer for people with diabetes to fast, particularly those with type 1 or insulin-treated type 2, who previously might have been advised not to fast. Says Dr Ali: “This is a really exciting time for people. Anecdotally, we all know, we’ve had people with type 1 diabetes who’ve wanted to fast and this is actually now giving them the opportunity to do so, safely.”

Professor Hanif agrees: “It used to be a battle telling people with type 1 diabetes not to fast, or just to fast for one day. But now with the closed loop systems, I am feeling more confident. There’s a lot of data coming from across the globe, small studies and small subsets of patients, but giving a kind of indication that people with type 1 diabetes on closed loop systems who monitor themselves closely, can fast safely. And I think that is a big shift because a lot of people with type 1 diabetes would like to fast for religious reasons, social or cultural reasons, and I think that is going to be quite fascinating.”

There is also the question of Ramadan’s timing, which changes every year according to the lunar calendar. In the northern hemisphere the fasts are getting shorter and there will come a time when Ramadan falls in winter months, putting it at odds with guidelines that were written at the time of summer when the fasts were very much longer.” Says Professor Hanif: “Somebody with type 1 diabetes cannot go without food for 18–20 hours. But now that’s changing, it’s time to really look at these risk scores and see how we could allow more people to fast.”

Might that include women with diabetes who are pregnant? “There still isn’t enough data on pregnancy and fasting,” says Dr Ali. “Pregnancy itself is an exemption to fasting. But of course, we do see people who wish to fast when they are pregnant. And if you’ve got diabetes, I think our recommendations will still be that you should not fast. Things may change with the advent of the technology and we’re giving technology a lot more to women with pregnancy and diabetes. But I think that we would still say that women with pre-existing diabetes who are pregnant should not fast. One thing that might be more interesting in the future is gestational diabetes. There are some studies coming from the Middle East… I still don’t think we’re in a place to say that women with or without diabetes should fast, but that might come in the future.”

See the full-length version of Professor Hanif and Dr Ali’s discussion on Horizons this week or watch the short version.

For more on this topic, enrol on the EASD e-Learning course Diabetes and Ramadan.

Any opinions expressed in this article are the responsibility of the EASD e-Learning Programme Director, Dr Eleanor D Kennedy.

---

Courses for which transcripts translated into Arabic are now available include the following:

• Technology and type 1 diabetes
  • Module 1: Basics of insulin pumping
  • Module 2: Continuous glucose monitoring
  • Module 3: Closed-loop systems
• Time in range
  • Module 1: Time in range – a new concept in glycaemic management

Translated transcripts are also available in Chinese (Mandarin) for the following courses:

• Hypoglycaemia
  • Module 1: Reducing hypoglycaemia
  • Module 2: Hypoglycaemia in older people
  • Module 3: Fear of hypoglycaemia
• Therapeutic inertia
  • Module 1: Therapeutic inertia in primary care
  • Module 2: Therapeutic inertia in type 2 diabetes

---