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Umm Amer is an apparently healthy woman in her mid-40s: slim, exercising regularly, adhering more or less to a healthy diet.

During Ramadan, however, Umm Amer, who requested to remain anonymous, does not fast. She was diagnosed with diabetes type 1 when she was nearly 20 years old, and fasting would put her life in danger, she told the Saudi Gazette.

With 23.9 percent, the Kingdom ranks No. 7 among the countries with the highest diabetes prevalence in the world, the latest studies estimate, and the number continues to increase year after year.

Should all these patients — around 3.6 million in the Kingdom alone — abstain from fasting?

Not contraindicated

“We usually don’t say that fasting is contraindicated in patients, but we say that is not recommended,” says Dr. Maimoona Mushtaq Ahmed, associate professor at King Abdulaziz University Hospital who is specialized in internal medicine.

Mushtaq does not want to tell patients not to fast because of the spiritual aspect attached to it. “In religious matters we cannot contraindicate,” meaning it is ultimately the patient’s decision to fast or not.

However, she admits there are “certain patients who should not fast during Ramadan.” Patients with kidney disease, ischemic heart disease — also called coronary artery disease, and diabetic patients who often experience hypoglycemia are examples of that. “Those [diabetics] whose blood sugar goes down frequently,” Mushtaq explains the term hypoglycemia, “are the ones who should not fast.”

Regularly, however, these patients do try to abstain from eating and drinking. In that case, the doctor will decrease the doses of insulin or oral hypoglycemics, “especially the doses before Suhoor” to prevent the blood sugar from getting too low during the fast. As a general thumb of rule, Mushtaq explains, diabetics take half of their normal evening dose of insulin at Suhoor and their usual morning dose following Iftar. Some other drugs do not need to be decreased at all.

But lowering the dose of insulin in the early morning is not without risks either: “In young patients with type 1 diabetes we get a lot of diabetic ketoacidosis during Ramadan,” Dr. Mushtaq, who works part time at AlMashfa Hospital as a general practitioner too, continues.

Diabetic ketoacidosis develops when the body does not get enough insulin to make the sugar in the blood enter the cells for energy. Consequently, the body starts breaking down fat as an alternative. This produces a buildup of toxic acids in the bloodstream called ketones, which can lead to diabetic ketoacidosis, a life-threatening complication.

Diet

The cause is usually the amount of sugary, carbohydrate-rich foods eaten during Ramadan. Mushtaq, therefore, advises patients to limit their carbohydrate intake, as they should do the rest of the year. Whatever instructions they have to follow before Ramadan they should continue during and after the Holy Month, she says, adding they also need to avoid fatty foods and eat three meals and two snacks, such as half an apple or one package of rusk bread, in between the meals to keep their blood glucose levels stable. The doctor also recommends people to have Suhoor right before the Fajr prayer to prevent hypoglycemia (low blood sugar) during the day.

Although doctors in the Kingdom generally do not contraindicate fasting to diabetic patients, they do stress the importance of monitoring blood sugar levels. This does not break the fast and is something patients can easily do at home throughout the day and night. If these levels get too low (below 60 mg/dL or 3.3 mmol/l) or too high (above 300 mg/dL or 16.7 mmol/l) the patient immediately has to break the fast even if it happens in the afternoon. Symptoms of low blood sugar are sweating, drowsiness, dizziness, and feeling shaky. Mushtaq also tells her patients to test their blood glucose levels before Iftar and Suhoor.

Education

“Those whose blood sugar levels are not well controlled and repeatedly go into hypoglycemia should not fast,” Mushtaq stresses, imploring that patients often do not follow the Islamic teachings that sick persons do not need to fast, but that nobody can force them not to fast.

The solution for this is education. Not only does the patient need to know his duties and rights in Islam, but also those around him.

Umm Amer, for instance, gets many comments when people find out she does not fast. Generally, they try to make you feel guilty, such as by telling you that their uncle has diabetes and is very sick, but does nevertheless fast, she says.

She, therefore, avoids eating in the company of other people, but would also help her and other people with chronic diseases if there was more awareness on the issue. “People sometimes blame you for giving preference to your own health rather than doing what God expects from us,” she says, adding she exactly does what is written in the Qur’an, which clearly indicates not to fast if it jeopardizes your own wellbeing.

Fortunately, there are currently many ways — lectures, pamphlets, and other programs — to educate patients and their families on diabetes and whether they can fast or not, but it takes time for people to understand, according to Mushtaq, who says friends and family members of diabetics can also help by not offering sugary or fatty foods or taking them out to restaurants.

Risks of fasting

Another danger of fasting for diabetics with borderline creatinine levels, which measures kidney function, is dehydration. The risk of dehydration depends on the circumstances of the person who fasts, such as whether he spends his day in a well air-conditioned room or out on the street, and how much exercise he does, but also whether he takes diuretics. Patients on a diuretic, a medicine that promotes the production of urine, cannot fast either, the doctor says.

Generally, Mushtaq continues, diabetic patients can fast if their blood sugar levels have been under control for at least three months prior to Ramadan, they are well educated and compliant, and they have no complications or comorbid diseases, including kidney failure, heart disease or brittle diabetes type 1.

The latter refers to a group of diabetics with severe instability of glycemic values characterized by frequent and unpredictable hypoglycemic and/or ketoacidosis episodes that cannot be explained by errors of patients or doctors. This is the case with Umm Amer, who says she sometimes fast on a weekend but never more than 4 days in a row.

Exercise

Regarding exercise, Mushtaq says praying Taraweeh, the evening prayers, is a good exercise for most diabetics. “It is not advised to exercise while fasting,” she adds, as this can easily lead to hypoglycemia, but during the night there is no contraindication whatsoever to continue an exercise regime or even begin one.

“The American Diabetic Association recommends us to have at least three to four times a week 30 minutes of real exercise, during which the heart rate exceeds 100,” and Mushtaq agrees. She stresses that exercise should not only be done during Ramadan, but throughout the entire year without any excuse. “One of my patients [lives in a] very small flat, so she used to walk around the dining table [to exercise]. She lost a lot of weight doing just that,” illustrates Mushtaq. According to her, all it takes to maintain an exercise routine are “willpower, education, and perseverance.”

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