Fasting for Patients with Diabetes Mellitus
Randa Soukieh, MD
Family Medicine
Rashed A. Alfarra, MD
Internal Medicine, Nephrology and Critical Care Medicine
Zaiba Jetpuri, DO, MBA, CPH, FAAFP
Family Medicine
Introduction:
Type 2 diabetes is a disorder that disrupts the way the body uses sugar. All the cells in the body need sugar to work normally. Sugar gets into the cells with the help of a hormone called insulin. Insulin is made by the pancreas, an organ in the abdomen. If there is not enough insulin, or if the body stops responding to insulin, sugar builds up in the blood causing harm to other organs. That is what happens to people with diabetes.
There are 2 different types of diabetes:
●Type 1 diabetes – In type 1 diabetes, the pancreas does not make insulin or makes very little insulin, usually diagnosed at young age or in childhood.
●Type 2 diabetes – In most people with type 2 diabetes, the body stops responding to insulin normally. Then, over time, the pancreas stops making enough insulin, type 2 is the most common type.
Ramadan is a lunar-based month, and its duration varies between 29 and 30 days. Muslims who fast during Ramadan must abstain from eating, drinking, use of oral medications, and smoking from pre-dawn to after sunset; however, there are no restrictions on food or fluid intake between sunset and dawn. Most people consume two meals per day during this month, one after sunset and the other before dawn.
This chapter will discuss the general recommendations for patients with diabetes and general guidelines for fasting during this holy month. Fasting is not meant to create excessive hardship on the Muslim individual according to religious tenets. Also of note, fasting is a spiritual issue for which patients make their own decision after receiving appropriate advice from religious teachings and from health care providers.
It is important to recognize the symptoms of low blood sugar, also called hypoglycemia. The symptoms of low blood sugar can include severe hunger, fatigue, exhaustion, dizziness, headache, blurred vision, shaking hands, sweating, and increased heart rate. Patients experiencing these symptoms are advised to immediately break their fast by drinking a sugary juice and to seek medical attention so they can undergo observation.
Diabetics who fast need to be aware of the potential health risks. They must also be ready to listen to the recommendations of their healthcare team to achieve a safer fasting experience.
Diabetic patients who are cleared to fast by their healthcare team are advised to drink plenty of water between Iftar and Suhoor, avoid overindulging in sweets and fats, check their blood sugar regularly, and immediately break their fast if they feel unwell or if their blood sugar drops.
The decision to fast carries an assortment of potential risks and complications for individuals with diabetes. Individuals with diabetes who choose to fast during the Holy Month should obtain a medical assessment and specific advice on medication and dietary adjustments. (see Table 1 below)
Pre-Ramadan Medical Assessment
All patients with diabetes who wish to fast during Ramadan should prepare by undergoing a medical assessment and engaging in a structured education program to undertake the fast as safely as possible. This assessment should take place 1–2 months before Ramadan. Specific attention should be devoted to patients' overall well-being and to the control of their glycemia, blood pressure, and lipids. Appropriate blood studies should be ordered and evaluated. Specific medical advice must be provided to individual patients concerning the potential risks they may experience if they decide to fast. During this assessment, necessary changes in diet or medication regimen should be made so that the patient initiates fasting while on a stable and effective program. This assessment should also extend to those who do not wish to fast because they often are exposed to the risk of hypo- and hyperglycemia during Ramadan as a reflection of social habits encountered during the month.
Management of patients with Type 1 diabetes
Fasting at Ramadan carries a very high risk for people with type 1 diabetes. This risk is particularly exacerbated in poorly controlled patients and those with limited access to medical care, hypoglycemic unawareness, unstable glycemic control, or recurrent hospitalizations. In addition, the risk is also very high in patients who are unwilling or unable to monitor their blood glucose levels several times daily. It is currently recommended that treatment regimens aimed at intensive glycemia management be used in patients with diabetes. Therefore, the most important thing is to monitor blood sugar closely while fasting. If patients with type 1 diabetes prefer to fast at Ramadan, the current understanding is that the basal-bolus regimen is the preferred protocol of management. It is thought to be safer, with fewer episodes of hyper- and hypoglycemia. A frequently used option is once- or twice-daily injections of intermediate or long-acting insulin along with premeal rapid-acting insulin. Using a Continuous glucose monitor (CGM) can help patients with Type 1 DM monitor sugars more closely.
Management of patients with type 2 diabetes
v Diet-controlled patients.
In patients with type 2 diabetes who are well controlled with lifestyle therapy alone, the risk associated with fasting is quite low. However, there is still a potential risk for occurrence of postprandial hyperglycemia (after meal high blood sugar) after the predawn and sunset meals if patients overindulge in eating. Distributing calories over two to three smaller meals during the non-fasting interval may help prevent excessive postprandial hyperglycemia. Physical activity may be modified in its intensity and timing, e.g., ∼2 h after the sunset meal.
Patients treated with oral agents
The choice of oral agents should be individualized. In general, agents that act by increasing insulin sensitivity are associated with a significantly lower risk of hypoglycemia than compounds that act by increasing insulin secretion.
Ø Metformin: Patients treated with metformin alone may safely fast because the possibility of severe hypoglycemia is minimal. However, perhaps the timing of the doses should be modified to provide two-thirds of the total daily dose with the sunset meal and the other third before the predawn meal.
Ø Glitazones: The thiazolidinedione or glitazone agents (pioglitazone and rosiglitazone) are not independently associated with hypoglycemia.
Ø Sulfonylureas: Such as glyburide or glimepiride. It has been suggested that this group of drugs is unsuitable for use during fasting because of the inherent risk of hypoglycemia.
Ø Short-acting insulin secretagogues. Members of this group (repaglinide and nateglinide):
are useful because of their short duration of action. They could be taken twice daily before sunset and predawn meals.
Ø Incretin-based therapy. dipeptidylpeptidase-4 inhibitors (DPP-4is) alogliptin, saxagliptin, sitagliptin, and vildagliptin:
These classes of agents are not independently associated with hypoglycemia, though they can increase the hypoglycemic effects of sulfonylureas, glinides, and insulin.
Ø Sodium-glucose Cotransporter 2 (SGLT2) inhibitors (empagliflozin): This class of medicine will not cause hypoglycemia but they can increase the amount of urination and cause symptoms of dizziness
Ø α-Glucosidase inhibitors (Acarbose and miglitol): slow the absorption of carbohydrates when taken with the first bite of a meal. Because they are not associated with an independent risk of hypoglycemia, particularly in the fasting state, they may be particularly useful during Ramadan.
Patients treated with injectable glucagon-like peptide-1 receptor agonists (GLP-1ras) semaglutide and liraglutide
Semaglutide can be dosed once a week to minimize appetite and promote weight loss. Liraglutide is dosed once a day, independent of meals, and is more effective in controlling fasting glycemia.
Patients treated with insulin.
Problems facing patients with type 2 diabetes who administer insulin are like those with type 1 diabetes, except that the incidence of hypoglycemia is less. Again, the aim is to maintain necessary levels of basal (intermediate or long acting) insulin to prevent fasting hyperglycemia with the goal of not skipping the predawn Suhoor meal. An effective strategy would be judicious use of intermediate- or long-acting insulin preparations plus a short-acting insulin administered before meals. Although hypoglycemia tends to be less frequent, it is still a risk, especially in patients who have required insulin therapy for several years or in whom insulin deficiency predominates in the pathophysiology; Very elderly patients with type 2 diabetes may be at especially substantial risk and is not recommended for them to fast.
Ø Insulin injections, using one injection of a long-acting or intermediate-acting insulin can provide adequate coverage in some patients if the dosage is appropriately individualized; however, most patients will require rapid- or short-acting insulin administered in combination with the basal insulin at meals, particularly at the evening meal, which typically contains a larger caloric load. There is some evidence suggesting that use of a rapid-acting insulin analog instead of regular human insulin before meals in patients with type 2 diabetes who fast during Ramadan is associated with less hypoglycemia.
Ø Insulin pumps, An insulin pump provides continuous insulin delivery over 24 h with basal infusion rates programmed and individualized for each patient. Patients self-administer boluses of insulin with meals or at times of hyperglycemia, often with mathematical support from the pump. The reliance on exclusively rapid-acting or short-acting insulin allows for flexibility over an extremely wide range of insulin doses with great precision. However, frequent glucose monitoring is required because failure of the pump or the infusion site can result in severe deterioration in control over a few hours. Theoretically, the combined risks of hypoglycemia from prolonged daytime fasting and hyperglycemia from excessive nighttime eating can be better managed by an insulin pump–based regimen than by multiple insulin dose–injection therapy. Hypoglycemia can be aborted, reduced, prevented, and even more readily treated in pump-treated patients by timely downward adjustments or even stopping insulin delivery from the pump. Such an advantage is not available to those treated with a conventional insulin injection in which insulin continues to be released from the site of injection throughout its predetermined duration of action. Any excess insulin action can only be counteracted by intake of carbohydrates.
General Recommendations and Precautions About Nutrition
o Diabetes management in patients who fast is highly individualized, and the plan will differ from patient to patient.
o It’s important NOT to skip the suhoor meal, which is just before dawn. High fiber starchy foods like high fiber cereals or oats, buckwheat, bulgur wheat or brown or wild rice are more slowly absorbed and have a low glycemic index. These foods take longer to digest.
o Be mindful of portion sizes of carbohydrate containing foods. These will help you to manage your blood sugar levels in the healthy target range while you’re fasting. It is especially important to incorporate proteins into your suhoor meal.
o Lentils and chickpeas are good sources of protein and are high in fiber
o Before starting the day’s fast, you should drink enough sugar-free and decaffeinated fluids to avoid being dehydrated during the day. If you drink tea, green tea is recommended as it will act as an appetite suppressant.
o Include more non starchy vegetables, such as broccoli, spinach, and green beans.
o Include fewer added sugars and refined grains, such as white bread, rice, and pasta with less than 2 grams of fiber per serving.
o When breaking the fast, dates are part of the traditional meal. These are high in fiber but can also be high in carbohydrates. Two large dates are around 20g carbohydrates so try to not eat more than one date.
o When breaking the fast, limit fatty and sugary foods ad avoid sugary drinks
o Follow The Plate Method: Portion control. It’s easy to eat more food than you need without realizing it. The plate method is a simple, visual way to make sure you get enough non starchy vegetables and lean protein while limiting the number of higher-carb foods you eat that have the highest impact on your blood sugar.
The Plate Method
Start with a 9-inch dinner plate (about the length of a business envelope):(see picture1 below )
Fill half with non-starchy vegetables, such as salad, green beans, broccoli, cauliflower, cabbage, and carrots.
Fill one quarter with a lean protein, such as chicken, turkey, beans, tofu, or eggs.
Fill one quarter with carbohydrate (Carb) foods. Foods that are higher in carbs include grains, starchy vegetables (such as potatoes and peas), rice, pasta, beans, fruit, and yogurt. A cup of milk also counts as a carb food.
Other considerations
If your blood glucose drops lower than 70 in the early hours of the fast, it would be advisable to break the fast since your blood glucose will drop further if you continue to fast.
If your blood glucose drops lower than 60 at any given time, it would be recommended to break the fast immediately and consume glucose tabs/sugary drink.
If your blood glucose is elevated to greater than 300, it would also be advisable to break the fast as your sugar will go higher if you delay treatment.
References
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4. https://www.myplate.gov/
