• Reference Number: HEY-167/2016
• Departments: Diabetes
• Last Updated: 1 June 2016

Introduction

This leaflet has been produced to give you general information about your condition.  Most of your questions should be answered by this leaflet.  It is not intended to replace the discussion between you and your doctor, but may act as a starting point for discussion.   If after reading it you have any concerns or require further explanation, please discuss this with a member of the healthcare team caring for you.

Fasting During Ramadan

Fasting during Ramadan is one of the five pillars of Islam and many people with diabetes choose to observe this religious duty. This leaflet will provide you with guidance.

Healthy Muslims may choose to fast during the Islamic month of Ramadan.  It is very important that you are seen by the diabetes team at least 6 to 8 weeks before fasting begins as this would help to ensure that your diabetes is stable.  In addition, it would be helpful for your family/relatives to be involved to discuss ways of correcting low blood glucose (‘hypos’) if this happens during the fast.

Certain groups of people may be exempt from fasting, for example:

• Children (under the age of puberty)
• Elderly and people who are sick
• People who have a learning disability
• People who are travelling
• Pregnant, breastfeeding and menstruating women
• Anyone who would be putting their health at serious risk, e.g. people who      treat their diabetes with insulin or have diabetic complications (damage to      their eyes, kidneys or the nerves in their hands and feet)
• Patients who have Type 1 diabetes (ie who started using insulin early after initial diagnosis of Diabetes)

If you do choose to fast, your diabetes team will work with you to try and keep your diabetes stable.

Changes to your diet

During Ramadan your eating pattern will be different.  There are only 2 meals per day, Sehri (early morning) and Iftar (evening).  Because of this you may experience large swings in your blood glucose levels because of the long gap between meals and larger amounts of food.  To help control blood glucose levels follow these dietary guidelines during Ramadan and see the tables below:

• Try to have the meal at Sehri just before sunrise not at midnight. This will spread out your energy intake more evenly and result in more balanced blood glucose when fasting.
• Include fruits, vegetables, dhal and yogurt in your meals at Iftar and Sehri.
• Limit fried foods eg paratha, puri, chevera, katlamas, fried kebabs and Bombay mix.
• Choose sugar-free types of fizzy drinks, decaffeinated drinks and cordials or water and use these to quench your thirst. Avoid adding sugar to hot drinks; use a sweetener where needed eg Canderel, Sweetex, Hermesetas.
• Fill up on starchy foods such as basmati rice, chapatti and pitta bread before you begin the fast.

Foods to avoid	Alternative foods
Deep fried pakoras, samosas, fried dumplings	Chickpeas, baked samosas, boiled dumplings
Indian sweets eg Ghulab, Rasgulla, Burfi, Balushahi, Baklawa, Mithai	Milk based sweets and puddings, eg Rasmalai, Barfee
High fat cooked foods, eg oily curries and pastries	Alternate with chapattis made without oil and baked or grilled meat and chicken.  Make pastry at home and use a single layer.

Cooking methods to avoid	Alternative cooking methods
Deep frying	Shallow frying, grilling, baking or dry frying.
Curries with excessive oil	Reduce the amount of oil used (eg use 1-2 tablespoons for a 4 person dish) and use more onions and tomatoes to bulk out the curry.

Activity

In general, normal levels of physical activity can be maintained but you should try to avoid strenuous activity (which causes shortness of breath so that you are unable to have a conversation) especially in the few hours before the Iftar meal due to the risk of hypoglycaemia.  If you participate in the Taraweeh prayer (extra prayers after the evening meal) then this should be considered part of the daily activity.

Changes to Diabetic Treatment

Diet alone

Those whose diabetes is controlled by diet and activity alone should be able to fast.  However, food and drink at break of fast should be given consideration.  Use low-calorie drinks, limit sweets and fried foods.

Diet and tablets

The timing of your tablets will change during Ramadan.  It is essential you take them to control your blood glucose levels and help keep you feeling well.

• If you usually take your diabetes tablets in the morning only, then take the same dose at Iftar instead.
• If you usually take your diabetes tablets twice a day, take your morning dose at Iftar and take half your normal evening dose at Sehri.
• If you usually take your tablets 3 times a day, consult your GP as the dose and timing will have to change.

Diet and insulin

• Your insulin doses will need to be changed so speak to your GP.
• Do not stop taking your insulin during Ramadan.
• To avoid low blood glucose (hypos), rest as much as possible during the day.

Monitoring during Ramadan

This is important as your blood glucose levels will vary.  It is important to test your blood glucose levels more often as they may drop too low (known as a hypo) particularly if you are unwell and/or treated with insulin or taking a sulphonyurea eg gliclazide, Glimepiride or Glipizide you are at risk of hypoglycaemia (hypo) as you are missing a meal.  Early signs may be shaking, sweating, hunger, palpitations.  Treating this mild stage will help to avoid the more severe stage with later signs like confusion and irrational behaviour.  If you experience any of the symptoms you must stop what you are doing, do the finger prick blood glucose test and if your blood glucose is less than 4mmol/l then treat.  You should also consider breaking the fast if your blood glucose level exceeds 16 mmol/L.

Treatment for a Hypo

• 100-120ml of Lucozade
• 150-200ml pure orange juice
• 5–6 glucose tablets
• 5 jelly babies
• 1-2 small tubes Glucogel (available on prescription)
• Follow this up with slower acting carbohydrate unless it is near a mealtime
• A sandwich (2 slices of bread)
• 1 piece of fruit
• 2 biscuits, or
• A glass of milk

 If a hypo is severe enough to cause unconsciousness, NOTHING SHOULD BE GIVEN BY MOUTH.

You should be put in the recovery position and an ambulance called immediately.  However, it is unusual for people with Type 2 diabetes controlled with tablets to have severe hypos.

Frequently asked questions:

Q.  Will testing my blood glucose be breaking the fast?

A.    No, this does not involve taking food or drink.

Q.   What is the best way to break the fast?

A.    Dates are commonly used to break the fast and 2 or 3 should be sufficient;         avoid eating other foods high in sugar and fat eg sweets.

Q.   Is Ramadan a good time to quit smoking?

A.    Yes. Allah has entrusted us with a healthy body and it is a violation to knowingly and willingly harm it. Ramadan provides a great opportunity to amend many bad habits such as smoking.

Q.   How do I reduce heartburn?

A.    Indigestion tablets such as Gaviscon, Zantac, Losec, and Zoton are advised at the pre-dawn meal. The control of belching can be reduced by eating in moderation and avoiding oily, deep-fried or very spicy food. Reducing caffeine, stopping smoking, and peppermint oil can benefit.

Q.   How do I treat constipation?

A.    Ensure you drink plenty of fluid outside of the fast. Increase the fibre content of your diet.  Choose high fibre cereals such as bran flakes or wheat based cereals.  Use wholemeal or granary bread and add chickpeas, butter beans and lentils to curries.

Q.   What do I do if I become dehydrated?

A.    We advise you to drink plenty before you fast to prevent increasing your risk of dehydration. The risk is higher in the elderly and those taking tablets such as diuretics. If you are unable to stand up due to dizziness or you are disorientated you should urgently rehydrate with regular, moderate quantities of water with sugar and salt added or use Dioralyte or Lucozade.

Should you require further advice and more information on the issues contained in this leaflet, please do not hesitate to contact your diabetes nurse, diabetes dietitian or doctor before fasting to discuss any changes you may need to your tablets or insulin.

The Diabetes Centre can be contacted on Telephone number:  (01482) 675340

Information about you

We collect and use your information to provide you with care and treatment.  As part of your care, your information will be shared between members of the healthcare team, some of whom you may not meet.  Your information may also be used to help train staff, to check the quality of our care, to manage and plan the health service and to help with research.  Wherever possible we use anonymous data.

We may pass on relevant information to other health organisations that provide you with care.  All information is treated as strictly confidential and is not given to anyone who does not need it.  If you have any concerns please ask your doctor, or the person caring for you.

Under the Data Protection Act (1998) we are responsible for maintaining the confidentiality of any information we hold about you.  For further information visit https://www.hey.nhs.uk/Patients/confidential-information-about-you.htm

This leaflet was produced by the Diabetes Department, Hull University Teaching Hospitals NHS Trust and will be reviewed in June 2019.