Most believers or followers of Islam around the globe fast during the holy month of Ramadan. It is an important spiritual practice for them. However many issues crop up if they suffer from diabetes. It is imperative up on every patient to communicate his plan in advance with his health care provider and devise a strategy to meet his nutritional requirements on one hand and navigate his blood glucose levels in the normal range without experiencing severe hypoglycaemias on the other hand during fasting period.
Most health problems are likely to arise from inappropriate diet or as a consequence of over-eating and insufficient sleep. Therefore, the diet during Ramadan for people with diabetes should not differ significantly from a healthy and balanced diet. The nutritional advice should be tailored to their special needs and medical problems. It should aim at maintaining body weight if they are lean, or reducing body weight if they are overweight or obese.
The nutritional requirements of every patient must be assessed by a registered dietitian and a custom made diet plan has to be proposed which should include principles of healthy eating behaviour, preventive methods for hypoglycaemia and proper portion intake.Since foods consumed during Ramadan tend to be higher in carbohydrate, strategies should include portion control as well as the possible incorporation of physical activity after meal.
Another important aspect of nutritional management during this period is to avoid hypoglycaemias and limit hyperglycaemic episodes.
Apart from switching to antihyperglycemic agents and limiting physical activity in the morning hours it is important to choose the right kind of food for Suhur or Sehri to prevent hypoglycaemias. To that end, it is important to drink plenty of fluids and include good portion of fruits in the diet. For energy needs, include fibre rich complex carbohydrates like whole grains to remain fuller for a longer time. They also help in digestion and avoid constipation. Try having breakfast as late as possible before initiating fasting to feel more satiated during the fast. Ideal food items to be included here are,
- Indian bread made of batter containing a mix of rice and urud flour (Dosa, idli etc)- If one wishes to ear savoury dishes, ensure less salt in them for want of reducing thirst during the day.
- Wholegrain or multigrain bread- Avoid eating salty food like preserved meat/ fish or pickles. Since bread is a dry food item, combine it with food like milk, fruit spreads etc.
- High fibre breakfast cereals- These food items are good source of micro-nutrients and when taken with milk, they help to meet fluid requirement as well.
- Yogurt- It is a good source of probiotics, micronutrients, protein and fluid. It can be combined with cereal and fruits.
- Fruits- Generally two fruit portion are recommended daily. Fruits with low glycaemic index like guava, papaya, pomegranate, apple, orange and pear can be included.
Now coming to Iftar, time to break the fast, prefer low fat and fluid-rich foods. Drink a lot of fluids to make up for the dehydration one may have acquired during the day. It may not be a good idea to consume foods or drinks with added sugar. Ideal food items to be included here are,
- Dates – Dates are being eaten to break the fast since the time of Prophet Mohammed. These offer natural sugar for energy and come packed with minerals such as manganese, copper, and potassium. It is a great source of fibre as well.Dates have a low glycaemic index (GI) provided it is consumed in a small amount About 4 regular size dates would make a portion of fruit.
- Kanji / Soup – Traditionally the broth contains beans, lentils and grains. It not only offers nutrients and energy but supply much needed fluids as well.
- Fruits- Fruits provide natural sugars for instant energy along with vitamins, minerals, and fluid as well. It is a good option to break the fast.
- Drinks- One can also break the fast by drinking low-fat milk, water or fruit juices. Water provides hydration without added sugar or extra calories. Milk or fruit based drinks also help offer nutrients and natural sugars. Avoid using carbonated drinks with extra sugar since they are poor in nutrients and may cause hyperglycaemia in the evening.
Taraweeh Prayers
These are long night prayers, which are not obligatory but highly recommended, that last for 1–2 h. Taraweeh prayers can be a strenuous physical activity that could result in dehydration and increased risk of hypoglycaemia. Taraweeh prayers should be considered as a part of the daily exercise program. So patients are advised to monitor BG concentration, to eat starchy foods with Iftar, which are digested slowly, and to drink plenty of water before prayers. Patients with diabetes at risk or with a history of severe or recurrent hypoglycaemia should be treated with agents with a low risk of hypoglycaemia or advised to reduce the total daily dose of insulin during Ramadan and Taraweeh prayers1.
Since the number of meals are limited, make sure that each meal one consume is well balanced in terms of macronutrient proportion, micronutrients and fluids. So each meals should have wholegrain, vegetables, fruits, protein rich foods like chicken, fish, lentils and eggs.
Breaking the fast
All patients should understand that they must always and immediately end their fast if hypoglycaemia (blood glucose of <60 mg/dl) occurs because their blood glucose may drop further if they delay treatment. The fast should also be broken if blood glucose reaches <70 mg/dl in the first few hours after the start of the fast, especially if insulin, sulfonylurea drugs are taken at predawn. Finally, the fast should be broken if blood glucose exceeds 300 mg/dl. Patients should avoid fasting on “sick days2.”
It is important to inform patients that blood glucose testing during Ramadan does not break the fast; a common misconception in some parts of the world. Blood glucose should be regularly monitored during fasting, especially those on insulin or insulin secretagogues3.
Type 1 Diabetes Mellitus
In general, patients with type 1 diabetes,especially if “brittle” or poorly controlled, are at very high risk of developing severe complications and should be strongly advised to not fast during Ramadan. In addition, patients who are unwilling or unable to monitor their blood glucose levels multiple times daily are at high risk and should be advised to not fast.
References:
- BMJ Open Diabetes Research and Care 2015;3:e000108. doi:10.1136/bmjdrc-2015-000108
- Diabetes Care, volume 28, number 9, September 2005
- BMJ Open Diab Res Care;8:e001248. doi:10.1136/bmjdrc-2020-001248
- Diabetes Research and Clinical Practice, Volume 126, April 2017.