Observing Ramadan by Diabetic patients

      

Diabetes and Ramadan

         

The commandment of fasting

Ramadan the holy month

Ramadan ((/ˌræməˈdɑːn/; رمضان), the ninth month of the Hijri calendar, is observed by Muslims all over the world. It is the month in which Muslims are committed to fast as the Fifth Pillar of Islam. Fasting means refrainment from consuming food, drinking liquids, and sexual engagement from dawn to dusk. Praying and recitation of the Holy Qur’an are increasingly practiced in Ramadan to gain the mercy and grace of Allah. Fasting of Ramadan is obligatory upon sane, healthy and adult Muslims all through the 29 or 30 days of the month according to the moon-seeing of the crescent (Helal,هلال ) of the Holy Month from the sunset (Maghrib, مغرب) to the predawn time (Souhour, سحور).

Allah says in the Holy Qur’an that “O’ Believers, fasting is decreed for you as it was decreed for those before you; perchance you will be self-restraint (2:183) (Fast) a certain number of days, but if anyone of you is ill or on a journey let him (fast) a similar number of days later on; and for those who are unable (to fast), there is a ransom the feeding of a needy person. Whosoever volunteers good, it is good for him; but to fast is better for you if you but knew (2:184).”[i] Prophet Muhammad (PBUH ﷺ) said, "Whoever observes the fast during the month of Ramadan, (while) believing in Allah and seeking His rewards, will have his past sins forgiven." [Reported by Imam Bukhari, Muslim and others]. The wording of the Holy Verses and the wording of Hadith make Fasting of Ramadan and obligation (Fard, فرض) upon Muslims seeking for the good rewarding from Allah.

During the Holy Month of Ramadan, the gates of Paradise are opened and that of Hell are closed. This is a great hope for Muslims to do their best to be forgiven and the sins to be nullified as if he/ she were born that day. The Hadith narrated: Narrated Abu Hurairah: The Messenger of Allah (ﷺ) used to commend prayer at night during Ramadan, but did not command it as a duty. He would say: If anyone prays during the night in Ramadan because of faith and seeking his reward from Allah, his previous sins will be forgiven for him.” (Sunan Abi Dawud 1371, authenticated by Al-Albany).

The Messenger of Allah (ﷺ) used to commend prayers at night during Ramadan but did not command it as a duty. He would say: If anyone prays during the night in Ramadan because of faith and seeking his reward from Allah, his previous sins will be forgiven for him.

 The spiritual meaning of fast in Islam:

Muslim who observes fast in Ramadan does this out of deep love for Allah. Man, who loves Allah is the man who knows the sincere meaning of love. Fast teaches us, love.

Muslim who observes fast in Ramadan does this hoping the pleasing and grace of Allah. Those who are seeking the pleasing and grace of Allah are supported by hope and an optimistic prospect of life. Fast teaches us to hope.

When Muslim fasts, he/ she does this for Allah and for His sake alone. Muslim is devoted only to Allah and is dedicated only to Allah. Fast teaches us the genuine virtue of honesty.

When Muslim fasts, he/ she keeps fast in secret as well as in public. There is no authority to check his/ her fasting or compel anyone to fast. Muslim keeps fasting seeking the pleasing and grace of Allah. Fast teaches us a sound conscience.

Fast teaches us patience and selflessness. The fast Muslim feels the pain of deprivation and endures the pain patiently.

Fast teaches us moderation.

Fast teaches us to be humble.

Fast teaches us discipline and healthy living.

Fast teaches us self-reassurance and self-control. Fast teaches the Muslim who to control his/ her desires and lust deliberately for 30 days to be released only as per Allah commandments to win His grace and mercy. All over the year, the Muslim will not submit to the call of the desires and lust because he/ she knows how to resist.

When Muslim eats or drinks because of forgetfulness, observation of fast is not nullified. On the contrary, the Muslim should stop eating or drinking immediately and continue fasting. It is highly recommended by Prophet Mohammed (PBUH, ﷺ) to take care of the following:

-          To delay Suhoor to as late as possible. It is a blessing; as narrated by Abu Huraira may God be pleased with him, the Messenger of Allah (PBUH, ﷺ) said: "Eat Suhoor, surely there is a blessing in Suhoor" (Al-Bukhary 91923 & Muslim, 1095). Also, Hadith that depends on the narration by Aby Sa'id Al Khodry that Allah's Apostle said: "Suhoor is a blessed meal, so do not leave it even if you only take a gulp of water, as Allah and his angels are praying for the people who eat Suhoor" (Ahmed, declared authentic by Al-Albany, 1070).

-          To break the fast by a few dates in an odd number or drinking plain water. It was narrated by Abu Hurairah that the messenger of Allah said: “The people will remain upon goodness so long as they hasten the break of the fast. Hasten to the break the fast for the Jews delay it.”  (Sunan Ibn Majah). The messenger of Allah was breaking his fast with fresh dates before payer of Maghrib. Anas bin Malik narrated: “The Messenger of Allah would break the fast with fresh dates before performing payer. If there were no fresh dates then (her would break the fast) with dried dates, and if there were no dried dates then he would take a few sips of water.” (Jami Al-Tirmidhi, Narrated by Ahmed 12265 & Abu Dawood 2356). It is better for the healthy Muslim as well as the diabetic to break his/ her fast with fresh dates or dry dates. It was proved that dates contain fructose sugar that needs not insulin for utilization by the muscles. Moreover, dates do not cause a spike of sugar after Iftar. Therefore, the diabetic patient will benefit from the date and can go for the prayer of Maghrib safely. However, it is advised that the diabetic Muslim keep some sugary food during praying, just in case he/ she has hypoglycemia during praying.

-          To eat a small amount of food without reaching complete fullness. Muslim should consider one third for food, one third for drink and one third for breathing. The Hadith narration is: “Miqdam bin Ma'dikarib (May Allah be pleased with him) reported: I heard Messenger of Allah (ﷺ) say: "No man fills a container worse than his stomach. A few morsels that keep his back upright are sufficient for him. If he has to, then he should keep one-third for food, one-third for drink and one-third for his breathing." (Narrated by Al-Tirmidhi as a good Hadith)

-           

-          To consider Tarawih prayers.

-          To consider recitation of the Holy Qur’an.

-          To be patient and humble.

-          To avoid careless gossip and prejudiced look to women. 

The Night of Decree (Laylat Al-Kadr) is expected in the last 10 days of Ramadan. The Muslim intensify his worship prayers, recitations, and donation of Zakat. The Holy Qur’an said that “Indeed, we sent the Qur'an down during the Night of Decree (1) And what can make you know what is the Night of Decree? (2) The Night of Decree is better than a thousand months (3) The angels and the Spirit descend therein by permission of their Lord for every matter (5) Peace it is until the emergence of dawn (5).” (97:1-5).

who is exEmpted from fasting?

The mercy of Allah decreed that the weak and the travelers are exempted from Fasting of Ramadan. The weak are those who cannot endure the fasting hours of Ramadan and their health will be badly affected. Those exempted because of their inability to endure fasting are the sick persons, the aged, and women suffering from post-childbirth bleeding or menstruating. Pregnant and lactating Muslim women have the choice to fast or not according to their health and endurance as well as the health of the child.

Sick persons are allowed to break their fast or not-to-fast at all when sickness is severe and unendurable. Muslims with an illness that will be worse by fast or the recovery of which will be delayed are premised to break their fast. The fear of being ill when fast equals to the fear of getting worse by fasting when one is ill. Sick people who suffer hardship or cannot endure fast are premised to beak their fast. Islam is keen to keep the health and life of Muslim during fast and not endangering the Muslim’s life because of his or her worshipping. All the scholars of Islam agreed upon saving the Muslim health and life during the fast and submitting to the commandment of Allah that the sick persons are exempted from fasting Al-Mughni (4/403). You sick Muslims, you are permised to break your fast in Ramadan without committing any sin.

the epidemiology of diabetics in ramadan

A landmark Epidemiology of Diabetes and Ramadan (EPIDIAR) study that was conducted in 2001enrolled more than 12,000 Muslim people living in 13 countries. Around 80% of the population of the study were urban; a mean age of 31 years for type 1 diabetes and 54 years for type 2 diabetes. Self-monitoring of the blood glucose level was 67% of patient with type 1 diabetes and 37% of patients with type 2 diabetes. Out of these percentage, only 43% of patients with type 1 diabetes completed only 15 days of fasting of the Holy Month. Those who have type 2 diabetes and observed fast of half of the month were 78.7% of the population enrolled in the study[ii]. The study reported that approximately 50% of the patients enrolled in the study did not change their lifestyle during fasting the Holy Month including physical activity, sleep duration and type and amount of food intake. Although medical advice was given to most of them, their lifestyle did not show any changes. Hypoglycemia episodes per patient per month were higher in Ramadan than the prior non-fast months. Those who changed their oral medication were subjected to hypoglycemia by 39% compared to those who changed their insulin injection regimen; 55%. Only 20% of patients who maintained their oral medications and 37% of those who maintained their insulin injection regimen did not have severe hypoglycemic episodes. The same study observed high incidence of hyperglycemic episodes among the patients with type 2 diabetes. In 2009, those who are adherent and committed to Islam were 1.57B averaging 23% of the general population (6.8B)[iii]. The growth of Muslim population is about 3% per year. The estimation of the number of Muslims with diabetes worldwide approaches 148M Muslims in 2005.

In 2010, a multi-country, retrospective, observational study of the management and outcomes of patient type 2 diabetes in Ramadan (CREED) enrolling 508 physicians in 14 countries and a total of 3777 patients reported that most of the diabetic Muslims fast every day in Ramadan. Around 94% of diabetic Muslims who fast more than 15 days during Ramadan still can fast nearly every day (32.4%) or every day (67.6%). These figures reported from the study indicate that despite the recommendations of the American Diabetic Association (ADA), patients who are at high and very high risk of adverse effects of diabetes during the fasting hours choose to fast every day of the Holy Month[iv].

The recommendations of these two studies and as well as studies are as follows:

·         The prevalence of diabetic Muslims is predicted to increase by the year 2040 as the global prevalence of diabetic patients will increase throughout the world up to the 642M patient.

·         The estimated number of diabetic Muslims reached 148M by 2005.

·         The majority of diabetic patients who are exempted by the religious rules and recommended not-to-fast by the physicians insist to fast; they fast at least 15 days of the Holy Month.

·         Although the diabetic guidelines are delivered to the diabetic Muslims in line with the advent of guidelines of ADA, only a small proportion of diabetic Muslims are compliant with the guidelines.

·         Efforts should be exerted by both the physicians and the religious figures in each locality to convince the diabetic Muslims that following the guidelines of the Muslim physicians are for their good. They should put more emphasis on the fact that the Muslim who is premised not-to-fast is rewarded equally to those who are submitted to fasting as long as he/ she donate food to the needy.

·         The rapid development of medicine and technology and the accumulation of data from the studies conducted in the Muslim world will help the patients with diabetes to fast safely during the day of the Holy Month. For example, the development of the new generation of oral anti-diabetic medication with low risk of hypoglycemia empowers the diabetic Muslims with type 2 diabetes to fast the Holy Month safely.

Fasting in ramadan

should Muslim with diabetes fast in ramadan?

Worship of Allah is the core spiritual practice of all Muslims all over their entire life. However, Allah provided Muslims with obvious permissions for their safety and well-being. Allah exempted the sick people, among many other categories, from fasting the Holy month of Ramadan. Therefore, Muslims are recommended not-to-fast entirely during Ramadan if fasting negatively impact their health or when fearing of such negative impaction.

People who determine to fast inspite of the flexibility of Islam and the obvious permission to eat and drink consider non-fasting shameful and disgraceful. They have a strong urge to continue the habit of fast seeking solidarity with the family and friends. They want to appear normal, leading a normal life including the fast of Ramadan. The physicians do extensive research to establish a special program and proper recommendations for Muslims who determine to fast against the medical advice. Diabetic patient should discuss the issue carefully with their health workers as well as the Imam to make the proper decision and get the optimum care during the Holy Month. The dramatic advance in medicine and technology succeeded to put most of the chronic diseases under control for long periods of time enabling people to practice their daily life activities without limitations. Such development encouraged people to attempt fasting inspite of being sick as long as they are under close medical supervision.

People with type 1 diabetes are recommended not-to-fast. They should not stop taking insulin otherwise they will have diabetic ketoacidosis. Taking insulin without food endangering them with hypoglycemia (low blood glucose level). The body will need to take in more calories than normal to compensate for the fasting hours. So, after breaking fast the body is at risk of hyperglycemia (high blood glucose level). Both hypoglycemia and hyperglycemia are not for good of the patients. That is why fasting for type 1 diabetes is not recommended.

Muslims with diabetes of any type should refrain from fasting when they suffer any complications of diabetic illness such as infection, kidney disorders, or cardiac problems. Fasting will put them at risk of worsening their condition. They need special treatment and medical observation. Carrying out the permissions of Allah is as worshipping as submitting to His commandments. A diabetic patient who cannot fast is expected to donate meals to the poor and needy. Here, it is better to emphasize that final decision should be based on the opinion of the Imam (fatwa, فتوى ) and the sincere consultation of your Muslim doctor.

Why fasting is not recommended in Ramadan for diabetic Muslims

According to the clear and obvious religious and medical recommendations, the fasting of diabetic Muslims is contraindicated in Ramadan. Those who suffer low glucose level (hypoglycemia) and acidotic blood (diabetic ketoacidosis) 3 months before Ramadan are absolutely contraindicated to fast. Diabetic patients with severe small vessels complications (microvascular) including kidney disease (diabetic renal insufficiency) and retinal complications (diabetic retinopathy) are not allowed to fast. There is a major risk of worsening their diabetic state upon fasting. Diabetic Muslims with large vessel diseases (macroangiopathy) such as uncontrolled hypertension (high blood pressure), heart disease (angina) and brain stroke (diabetic cerebral stroke) are stressed not-to-fast in Ramadan. They need high special care in special institutes. When the patient has an infection that is not related to diet or medicine should not fast until the infection is set under control. Pregnant women with diabetes should not attempt to fast. They are subject to a great risk as well as the baby. Aged Muslims with diabetes should be convinced not fast and donate food instead[v].

major diabetic complications of fasting in ramadan

Hypoglycemia and hyperglycemia

Hypoglycemia means a decrease in blood glucose level below 70 mg/dl (3.9 mmol/l). hyperglycemia means an increase in blood glucose level above 200 mg/dl (11.1 mmol/l). The latter condition may risk patients with type 1 diabetes with diabetic ketoacidosis.

Hypoglycemia is more dangerous and more fatal than hyperglycemia. The decrease of blood glucose level leads to alteration of the conscious level, sweating, and tremors. Within hours the patient with severe hypoglycemia is at risk of brain damage and death. Every diabetic patient should be aware of the signs of hypoglycemia and should break his fast upon the slightest suspicions of having low blood glucose level to save his life.

On the other hand, hyperglycemia would take a long time before risking the patient health and life. Therefore, the patient has a considerable time to go to the hospital for proper diagnosis and receiving the proper management. Measuring your blood glucose level during the fasting hours of Ramadan is not condemned by the scholars of Islam. When the blood glucose level exceeds the upper limit, 200 mg/dl, the patient should break the fast and ask for medical advice to adjust the blood glucose level including hospital visit when necessary.

Diabetic ketoacidosis

During fasting, the body suffers lack of glucose. To maintain the blood glucose level at the normal level, the body tends to use fat as an alternative source of energy. As a consequence of burning fat, a waste product called ketones increases excessively in the blood rendering the blood acidic. Blood acidity, in return, risks body health and life. Patients with type 1 diabetes produce no insulin in their bodies. They depend on the external insulin administration to maintain utilization of glucose. During the fasting hours of Ramadan, the patients are subject to excessive insulin reduction thus, they are at risk of diabetic ketoacidosis. Type 1 diabetics are at higher risk of ketoacidosis than those patients with type 2 diabetes. Those Muslims with type 1 diabetes are not recommended to fast at all especially when they suffer attacks of hyperglycemia before the Holy Month.

Dehydration and thrombosis

The diabetic patients who are intended to fast the Holy Month should keep their body hydrated and humid. Lack of water intake during the fasting hours, as well as the hot weather in some countries, causes the blood to become viscid (sticky). Increase blood viscosity participate in blood clot formation. When blood clots occur, the health of the patient is in danger of complications such as heart attack, renal insufficiency, and brain strokes. The recommendation is to keep in well air-conditioned places and drink plenty of water during the non-fasting hours.

diabetic muslim traditions in ramadan

From dusk to sunset Muslims are forbidden to eat, drink or have sex in the day hours of Ramadan. Fasting includes not taking medicine and not to smoke as well. Overnight, people habits vary. People can have one up to three regular types of meat including Breakfast (Iftar) and Souhour. People are devoted to worship of Allah by praying and recitation of the Holy Qur’an. However, some people develop the habit of excessive snacks eating overnight. It is not a healthy habit and not recommended both for diabetics and healthy people.

Family visits and friend meeting in Ramadan’s nights are an encouraging habit that is very cheerfully prepared for. Food and soft drinks are served during such festive meetings and visits. Food and soft drinks contain always a high amount of sugar and fat. The high caloric content of such food is not recommended for diabetic people. Diabetic patients avoid such meetings and visits which temptation is considered a challenge to the strict regimen of the diabetic Muslims. They find respecting the diet regimen difficult. They need to excuse frequently every time they are invited to taste this food or that.

The diabetic patients are submitted to the tremendous temptation of the nice smell of the homemade bread, cakes, dates, and honey. There is a lot of exotic food in the evening including the grilled meet the challenge of which is hopeless. No one can resist the smell of lamb meat cooked with sugar, dried plums and lemon flavor. Zalabia is a famous sweet in Ramadan. Zalabia is a fried, crispy cakes soaked in honey and mixed with orange blossom water. One piece of Zalabia equals to 17 pieces of sugar (290 Kcal)[vi]. “Sugar Bomb,” the name given to semolina (Kalb El Louz), contains 370 Kcal per portion that is equivalent to 87 g of sugar. Wherever you go all over the world you will find such high caloric food made and sold excessively and especially in Ramadan. How the clinician advice their patients to avoid such delicious food during the nights of Ramadan?

The temptation is at its highest in Ramadan because of the day hunger that exaggerates the psychological craving for food. It is well known that food of high caloric value increases dramatically during the month of Ramadan. One study traced such increase in food consumption stated that sugar consumption which was 24 kg/ year/ person in 2009 (2/kg/month) is doubled in Ramadan[vii]. Psychologically, hungry persons buy more food than they need actually. When you have low blood glucose level, your appetite is stimulated dramatically driving you to eat more food than your needs. At night, you will be ready to consume more than your actual need. Such habit risks the healthy people to have increased in weight by the end of the month with all its bad consequences including the risk to have diabetes. The diabetic people are at risk of hyperglycemia and other complications.

The diabetic Muslim in Ramadan faces a great dilemma “eat or not to eat.” The common question that is directed to the clinicians is “how much is allowed for me to eat?” The answer to the question need an accurate calculation to the caloric content of the high caloric food as well as the equivalent insulin or oral medication. Some patients increase their insulin dose or take more pills. The injudicious increase of anti-hyperglycemic medicine will put the patient at risk of hypoglycemia endangering his/ her life. The physicians in the Muslim world identified a marked increase in the patients who come to the hospital with severe forms of diabetic complications. Many diabetic Muslims consult their physicians before Ramadan. However, they are hardly following the regimen stated by their physician during Ramadan. The temptation of the sugary food is beyond their resistance. Nowadays, diabetic food is recommended to be served in an attractive spectacle and with a tempting smell. Most of the cakes and sweaty food are available made of low caloric value.

who is at risk?

Diabetic patients are classified into three categories as regarding their risk of complications during the fasting hours of Ramadan. Those who are at high risk are highly recommended not to eat. The Islamic scholar recommend a donation of their average food.

people at high risk: not recommended to fast

Ø  Patients with type 1 diabetes with poor control of their diabetic state.

Ø  Receiving high dose of insulin per day (twice daily injection)

Ø  Poorly controlled diabetic blood glucose.

Ø  Frequent attacks of low blood glucose level (hypoglycemia), hypoglycemia with hospital admission 6 months before the Holy Month or hypoglycemia with no apparent symptoms.

Ø  High blood glucose (hyperglycemia) level needing hospital admission 6 months before the Holy Month.

Ø  Diabetic complications of the kidney, heat, liver or vision to any degree.

Ø  Diabetic complications such as a diabetic foot or ulcer and infection.

Ø  Pregnant diabetic ladies: pregnancy with pre-existing diabetes or gestational diabetes maintained on insulin and sulfonylurea.

Ø  Patient on renal dialysis: CKD stages: 4 &5.

Ø  Old aged with ill health.

people at moderate risk: may or may not fast

o   Poorly controlled diabetes type 2 diabetes

o   Well-controlled type 1 diabetes.

o   Well-controlled type 2 diabetes on multiple dose insulin or mixed insulin.

o   Pregnant ladies with type 2 diabetes controlled by diet or metformin only.

o   Chronic kidney disease stage 3.

o   Diabetic patients with macrovascular complications such as hypertension and cerebral stroke, however, the condition is stable.

o   Patients with other medical condition that may worsen diabetes during fast.

o   Diabetic patients who perform vigorous physical labor.

o   Receiving psychological medications that affect the cognition of the diabetic patient.

people at low risk of: premised to fast

      Well-controlled diabetic patients at least 3 months before the Holy Month

      Well-controlled diabetic patients on

o   Lifestyle therapy.

o   Metformin.

o   Acarbose.

o   Sitagliptin, Linagliptin, Pioglitazone and Dapagliflozin

o   injections such as Liraglutide[viii].

o   Basal insulin.

management of patients at risk during Ramadan:

The first and the second group:

v  The patients should receive intensive medical education before and during the Holy Month.

v  The diabetic patient should be in close contact with a professional healthcare provider.

v  The patient should learn how to check the blood glucose level using a reliable method and obtain the required skills.

v  Sticking to the medication adjustment recommendations as well as the diet regimen at Iftar.

v  Braking the fast: the patient with high risk should be oriented with the possibility of breaking their fast when the symptoms of hypoglycemia occur or when the blood glucose measure exceeds the optimum limits in either direction.

v  The frequent occurrence of the complications mandates the cessation of fast the rest of the Month.

The third group:

v  The third group should receive well-structured medical education by professional and well-trained medical personnel.

v  Regular monitoring of the blood glucose level.

v  Following the recommendations of medications adjustment during the Month.

Special population: type 1 diabetes:

Patients with type 1 diabetes are recommended not-to-fast because of the high risk of complications. However, it is found that when the patient with type 1 diabetes is stable, he/ she can fast most of the month with high safety profile. The patient with type 1 diabetes should be healthy, euglycemic, aware of the complications and management and compliant with his/ her management plan. The patient should be under strict medical supervision. One study showed that 61% of the type 1 diabetes enrolled in the study were able to complete the entire month with no serious complications. The patients and the caregivers were given intense medical education and training on insulin injection adjustment, nutrition, and activity before the Holy Month. They were under strict medical supervision with hotline contact during the prolonged days of fast. The study outcome showed a minimum of 5 cases of mild hypoglycemia and no cases of diabetic ketoacidosis[ix]. Another study was also encouraging as 76% of the enrolled patients were able to complete 25 days of the entire month without serious complications if any[x]. However, the study shed a strong light on the occurrence of unrecognized hypoglycemia attacks. Such observation makes the use of the self-monitoring blood glucose level (SMBG) a vital tool to detect this condition. The patient should be aware of such episodes of hypoglycemia unawareness.

The strategies that should be followed to ensure safety of patients with type 1 diabetes during fast of Ramadan should include: 1- Ramadan-oriented medical education; 2- Pre-Ramadan medical assessment including hypoglycemia awareness; 3- Adopting healthy diet regimen; 4- Adopting physical activity plan; 5- Proper modification of insulin regimen; 6- Self-monitoring blood glucose level (SMBG) or continuous glucose monitoring.

Special population: the aged:

The aged persons are used to fast for years. It is a hard time when the aged are faced with the decision of not-to-fast. This decision represents a challenge to him or her. The aged may feel sinful for not-to-fast. Some aged may have depressive symptoms as not-to-fast means that they are close to their destiny more than before. The decision of not-to-fast should not be based on the age factor only. Many other factors should be considered as well. the aged diabetic Muslim who used to fast for many years would have other comorbidities that represent an additional challenge to fast in Ramadan. The aged should be carefully assessed for the impact of comorbidity on the health. The cognitive functionality should be assessed as well. Medications other than anti-diabetics should be reviewed as regards the influence of such medications on the glycemic status. The companions of the aged should be aware of the diabetes complications mainly the hypo- and hyperglycemia and the prompt management options. The aged diabetics with ill health and comorbidities are categorized as high-risk group patients.

pathophysiology of fasting of diabetic patients in ramadan

what happens during the fasting hours?

general:

During the Holy Month of Ramadan, fasting Muslims avoid seeking specialized medical attention and obtaining medical guidelines for their illness during the fast hours. The main reason is probably the fear of receiving strong opposition from the physician to cease fast. This fear is at its utmost when the members of the family are convinced with the necessity of ceasing the fast for their diabetic patient. Denial of the presence of complications or any problem is the second important reason. However, the impact of the fast hours of the day of Ramadan makes medical counseling before the fast Month a highly recommended advice.

The onset of Ramadan heralds many changes that concern the lifestyle of the patient including the following:

·         The shift of the mealtime: the diabetic Muslim fasts all day and eats all the night. The fast hours are usually longer than the eating hours. This shift threatens the patient hypoglycemia during the day and hyperglycemia after Iftar.

·         The shift of the activity pattern: most of the Muslims keep awake all night and sleep after Fajer prayer till Noon prayer.

·         The shift of the sleeping pattern: the diabetic patient sleeps most of the day and keeps awake most of the night.

The fast hours duration and the change of the rhythm of sleep and rhythm activity exert a tremendous impact on the physiological milieu of the body including internal homeostasis and endocrine processes.

changes in the sleeping pattern and circadian rhythm:

During Ramadan, the Muslim wakes up at dawn for Suhoor and prayer. The Muslim returns to sleep to wake up again to start the daily activity. Then, the Muslim sleeps again in the afternoon. Following Iftar, the Muslim keeps awake for eating and prayer until midnight. That is how the sleeping pattern is altered and distorted. Medical studies on the sleeping pattern during the Holy Month show the following:

v  Lowering of the total sleep time compared to the non-Ramadan time.

v  Decrease sleep period time.

v  Decreased the duration of continuous sleep.

v  Decreased the Rapid Eye Movement (REM) sleep duration.

v  Decrease the proportion of REM sleep.

v  Increase the proportion of non-REM sleep.

The previous changes lead to sleep deprivation that has been proved to be strongly associated with diabetic complications. There is a newly detected correlation between sleep deprivation and insulin resistance[xi]. The impact of such correlation to fast during Ramadan has not well studied yet.

The alteration in the sleep pattern, as well as the food intake, are detected to have an impact on the circadian rhythm. The circadian rhythm is indicated by changes in body temperature and cortisol levels. One study reported a major shift in the cortisol circadian rhythm. The level of cortisol decreases in the morning and rises in the evening[xii]. In Ramadan, the shift of the cortisol circadian rhythm starts at the 7^th day of Ramadan and revert to the normal pattern at the day 21^st. The authors refer the feeling of lethargy during the day of Ramadan to the alteration of the circadian rhythm.

Effect on glycemic control:

Patient with type 1 and type 2 diabetes, fasting leads the body to use glycogen as the source of energy in the liver. This process leads to the new formation of ketones. The body secrets a peptide hormone called glucagon. Glucagon is produced by the alpha cells in the pancreas. Its main function is to raise the concentration of both glucose and fat. During the fast hours, the low glucose level stimulates the secretion of glucagon to help elevate the blood glucose level by activating the utilization of glycogen as a source of energy. However, the body may fail to produce adequate amounts of glucagon in response to low blood glucose level. The failure to produce glucagon leads to hypoglycemia that increases 4.7-7.5 folds in Ramadan. Other complications that may occur in Ramadan include hyperglycemia, diabetic ketoacidosis, dehydration, and thrombosis. Such complications cast a great risk to the patient health and vitality[xiii].

Continuous glucose monitor studies have been conducted in the past few years involving patients with type 1 and type 2 diabetes. These studies showed no significant difference in glycemic control parameters between Ramadan and non-Ramadan periods. The studies showed no significant difference as regards the number of glucose excursions, time spent in the euglycemic state, hypoglycemia, and hyperglycemia. On recent study, 2015, reported a rapid surge of glucose level after Iftar. The rapid surge could be related to many factors including high carbohydrate load after Iftar, inappropriate timing and dosing of anti-diabetic medications and hormonal changes[xiv].

effect on body weight:

The conducted studies showed no effect on the body weight in patients with type 1 and type 2 diabetes during Ramadan compared to the period before Ramadan. However small studies noticed weight loss as well[xv].

Effect on lipid:

The results of the few studies conducted on the lipid profile changes on healthy subjects were both favorable and unfavorable. The studies reported a reduction in cardiovascular risk, a slight decrease in cholesterol level, an increase in the LDL cholesterol[xvi].

Dehydration and thrombosis:

Dehydration (dryness) and thrombosis (blood clotting) are of major concern during the Holy Month. Dehydration is related to hot weather, vigorous exercise or exhaustive physical work. Moreover, hyperglycemia leads to diuresis (increased micturition) that will lead to dehydration. The serious impact of dehydration on the health of the patient is hypotension and falls. Falls in Ramadan can be attributed to both hypoglycemia and dehydration.

Thrombosis is another serious untoward effect of fasting of diabetic patients in Ramadan. A survey study conducted in Saudi Arabia showed an increase in the incidence of retinal vein thrombosis in Ramadan. The incidence of the retinal vein occlusion reached almost 30% of all cases enrolled in the study. The authors attributed the cause of thrombosis to dehydration[xvii].

In conclusion, the Holy Month is associated with favorable outcomes namely decrease of the body weight and changes of the lipid profile for good. The healthy individuals can benefit such favorable outcomes. However, diabetic patients are at risk of hypoglycemia, hyperglycemia, dehydration, and thrombosis more than the months before Ramadan. It is highly recommended that patient with diabetes particularly those with type 1 diabetes should seek medical attention before the Holy Month. They have the religious permission not-to-fast that should be considered as well.

marks of abnormal glucose blood level

Diabetic patients should learn the symptoms of low blood glucose level (hypoglycemia). They should learn how to manage the condition of hypoglycemia immediately.

symptoms of hypoglycemia

Hypoglycemia is a very serious condition. It develops within hours and risks the patient’s life. Diabetic patients should learn the symptoms of hypoglycemia. They should also learn how to manage the condition immediately. Also, people live with the patient or involved in his/ her community should know how to manage the condition of hypoglycemia and help the patient before entering the coma state. Diabetic patient should carry a medical alert ID card and information sheet. The alert ID card should include the basics of emergency treating hypoglycemia as well as hyperglycemia. Concise and clear information was developed by the American Diabetes Association to help the first responders to manage a patient with a hypoglycemic emergency.

The causes of hypoglycemia are either injection of a high dose of insulin, skipping a meal, eating a non-sugary meal for a long time, vigorous exercise or a combination of all of them. The symptoms of hypoglycemia develop when the blood glucose level reaches below 3.3 mmol/l.

The symptoms of hypoglycemia are sweating, shakiness, rapid heart rate, anxiety and feeling of hunger. Other symptoms include weakness, tiredness, dizziness and blurred vision. The patient may suffer alteration of conscious level ranging from drowsiness to coma and even death. Prompt management is mandatory. People with type 2 diabetes are more prone to hypoglycemia.

Management of hypoglycemia is an emergency condition:

·         First line: glucose administration in the form of dextrose 50 ml of dextrose 50% intravenously immediately. It is the most important emergency management medication.

·         Second line: glucose-elevating agents such as glucagon.

·         Third line: insulin secretion inhibitors such as diazoxide and octreotide.

·         Fourth line: antineoplastic agent streptozocin.

symptoms of hyperglycemia

High blood glucose level (hyperglycemia) occurs when the patient skips insulin injection dose or oral glucose-lowering medicine such as a sulfonylurea. Eating huge amounts of carbs and fatty meals that exceed the insulin dose effect can cause hyperglycemia as well. Patients with untreated infections are at high risk of hyperglycemia. Sedentary life and inactivity increase the risk of hyperglycemia. Strenuous activity with high blood glucose level and low blood insulin levels cause hyperglycemia.

Hyperglycemia develops within days or weeks. The symptoms include thirst, headaches, blurred vision, frequent micturition, and altered consciousness. The blood glucose level exceeds 16.7 mmol/l. Patient with high blood glucose level should receive the missed dose of insulin or take short-acting insulin injection. However, it is advised to visit the hospital for specialized emergency medications especially when the blood glucose level reaches 20.0 mmol/l with dryness and altered conscious level.

The medical treatment aims at:

·         Administration of adequate fluid load to restore the fluid-electrolyte balance and treat dehydration. Dehydration is the most serious abnormality that needs prompt management.

·         Proper management of acidosis if any. Detection of diabetic ketoacidosis, a special variant of hyperglycemia needs special management in the hospital by specialized physicians.

·         Slow reduction of plasma glucose concentration by slow insulin infusion. Rapid reduction of the high blood glucose level is not recommended.

·         Identification and management of electrolyte abnormality if any.

·         Identification of the underlying cause and its management.

·         Proper evaluation of the kidney functions. The kidney is usually affected by diabetes and should be checked in every occasion as well as on regular bases.

how to control your diabetic state in ramadan?

general rules:

Before going through this section, it is better to pay attention to an important fact that is ample discussion with the treating physician or your health care provider is very important in making up your mind. Taking the decision of fasting during the Holy Month needs awareness of the risks. Adherence to the recommendations of the healthcare provider is a very important issue that you should be ready for. It is worth noting that your peers are not your example. Your clinical condition and your physical body endurance would be different. The decision of not-to-fast should be tailored to each individual Muslim. The only universal agreement is that the sick people have religious permission to not-to-fast. Although fasting against the medical advice and irrespective of the given permission is a challenge, the choice of the patient should be respected by the health workers.

When you come to know that a friend of a family member with the apparently similar condition can fast this does not mean that you can do the same. There are versatile individual differences that the expert physician can address to you. Therefore, it is better to realize that the diabetic health care and the management plan during the Holy Month will differ for each diabetic Muslim. So, ample discussion of the issue of fasting of the Holy Month is essential for the Diabetic Muslim.

Before the beginning of Ramadan, it is highly recommended to have a means to monitor the blood glucose level accurately. The diabetic Muslim should be well trained in using such means efficiently and the gained information is reliable to make a serious decision. Such recommendation is especially directed to the diabetic Muslims who are maintained on insulin injections whether they are type 1 or 2. Those who are maintained on pills should consider this issue as a safety procedure to detect the bouts of low blood glucose level as early as possible.

When to break the fasting- all diabetic Muslims should learn that fast should be immediately broken and without delay when the blood glucose level, at any time during the day, drops beyond 60 mg/dl (3.3 mmol/l). when the blood glucose measurement is higher than 300 mg/dl (16.7 mmol/l), they should break their fasting as well. when you regularly measure your blood glucose level, consider the first few hours of the day as very important. When the blood glucose level is beyond 70 mg/dl (3.9 mmol/l) in the early hours of the fasting day, the diabetic Muslim is unlikely to continue the entire day without the risk of severe hypoglycemia. The patient should break the fast immediately. Those diabetic Muslims who are maintained on insulin, sulfonylurea, meglitinide should be very cautious to their blood glucose level especially in the first few hours of the fast day.

diet control during ramadan:

A. food

Diet during Ramadan should be healthy and balanced. The aim is maintaining the same body mass. In another way, nobody weight should increase or decrease during the Holy Month. Usually, 50-60% of Muslims show the sustained body weight during the Holy Month. Only 20-25% of Muslims show either decrease or increase of body weight in the Holy Month. Occasionally, massive weight loss more than 3 kg may occur[xviii].

Diabetic Muslim should avoid the habit of ingestion of tremendous amount of food rich in calories mainly the carbohydrates and fat. Complex carbohydrates take time for digestion and absorption. Therefore, it is better to save them for the pre-dawn meal. Such types will provide us with calories most of the day. On the other hand, simple carbohydrates that take short time for digestion and absorption is advisable for sunset breakfast.

carbohydrates (cabs):

Carbohydrates are categorized as simple and complex carbohydrates. Simple carbohydrates (carbs) are easy to digest and absorb in a short time. They go directly to your blood causing elevation of blood glucose level. It is useful to be consumed at the sunset breakfast in Ramadan. Simple carbs include all types of sugars. The types of sugar you may have in your community include raw sugar, brown sugar, corn syrup (high-fructose corn syrup) and fruit juice. Fructose and sucrose are simple sugars as well. According to Sunna, it is better to breakfast by drinking milk. Yogurt contains simple sugars as well. Milk contains simple carbs thus; your blood glucose will elevate immediately after breakfast.

A. Simple carbs to avoid:

1.      Soda: simple water is better than carbonated fluid. The latter generates gases that distend your abdomen giving you a false impression of satiety. Carbonated fluids have more hazards including electrolyte imbalance and low nutrition supply.

2.      Baked treats: fruits are better especially dates. Date contains simple sugars that help the fasting Muslim to get the needed glucose. Dates contain fructose sugar that similar to glucose. Unlike glucose, fructose sugar does not need insulin to produce energy. This is a good advantage for the diabetic people in general.

3.      Packaged cookies: it is adviced to such cookies at home by yourself. You may use substitutes like applesauce or sweeteners to control the caloric contents of the cookies.

4.      Fruit juice concentrate: the best way to use the concentrate is to dilute it as much as you can to get a small amount of sugar rather than the huge amount of the concentrate per service. Fresh fruit juice made at home it better than the concentrate. If you had to, you should choose the 100% fruit juice instead.

5.      Breakfast cereal: in the Western community the breakfast cereal is very common. The advice is choosing the best for your health[xix]

On the other hand, Complex carbohydrates contain fiber and starch. They are characterized by being digested and absorbed slowly. This property is very beneficial for diabetic Muslims. The complex carbs are filling agents that delay the sense of hunger to many hours. The slow digestion and absorption render them suitable for a pre-dawn meal (Suhour). The delayed absorption serves to provide the body of the fasting Muslim with sugar during the day of Ramadan. The level will be maintained on a plateau level thus avoiding the blood sugar spikes or drops that are harmful to the diabetic patients. Fiber, in addition, promotes bowel regular motility. They are very useful in maintaining your weight during the Holy Month. Diabetic patients would suffer less constipation during the day when consuming fiber at pre-dawn meals.

B. Foods with high fiber content:

1.      Fruits

2.      Vegetables

3.      Nuts

4.      Beans

5.      Whole grains

C. Food with high starch content:

1.      Whole wheat bread

2.      Cereal

3.      Oats

4.      Peas

5.      Rice

Recommended complex carbohydrates:

1- Grains: they are a rich source of fibers. They also contain important minerals including potassium, magnesium, and selenium. Less processed whole grain is advised such as whole-wheat pasta and buckwheat. For diabetic Muslims, greasy additives should be avoided.

2- Fiber-rich fruits: fresh apples, berries, and bananas are advised.

3- Fiber-rich vegetables: green vegetables such as broccoli, leafy greens, and carrots.

Eating carbohydrates should be adjusted with your insulin injection dose. When you have more carbs than your insulin supply, the blood glucose sugar will rise. The reverse is true. When you have fewer carbohydrates, the blood glucose level will seriously go down. Therefore, you should count your carbs consumption.

One serving of carbohydrate diet is equal to 15 grams of carbs. Adults would need 2-4 carb servings at each meal and 1-2 snakes. It is better to consult a dietitian to help sort out the carbs count according to your specific needs. Carb counting is useful for patients with more than one daily injection of insulin as well as those with an insulin pump. When you need some flexibility in your food choice, you should resort to carbs count or consult a professional dietitian.

The recommendations of the American Diabetic Association:

§  For good health of diabetic patients, carbs intake from vegetables, fruits, whole grains, legumes, and dairy products are advised. Other carbs source that contain fats, sugars, or sodium are condemned. [It is worth noting that dairy products are recommended by the ADA. A fact that was stated by Sunna more than one thousand and half years ago.]

§  The key strategy in achieving optimum glycemic control is carbohydrate monitoring. Carbs count, or experience-base experience are recommended.

§  It is allowed to substitute low-glycemic load foods for high-glycemic load foods and sucrose-containing foods for isocaloric amounts of carbs. However, such practice should be minimized not to dispose nutrient dense foods.

§  Diabetic patients are invited to consume the same amount of fiber and grain as the healthy individuals.

§  It is a good practice to consume the non-nutritive sweeteners. This practice helps reduce the overall calories.

Nutritive sweeteners:

Sucrose: it is called “table sugar.” It is composed of one molecule of glucose and one molecule of fructose. It proves 4 Kcal/gm. There is strong evidence that dietary sucrose is equivalent to starch regarding the caloric amount and glycemic profile. however, it causes weight gain.

Fructose: it is a monosaccharide that occur in fruits and some vegetables as well as honey. It has a good effect on the glycemic profile. Fructose has a better glycemic control than sucrose or starch. Fructose has no bad effect of triglycerides. The intake should be limited to 12% of the energy.

Non-nutritive sweeteners:

The non-nutritive sweeteners provide nearly no energy and have a sweet taste. There is no increase in blood glucose or insulin concentration when taken by healthy individuals. The FDA approved 7 non-nutritive sweeteners agents: sucralose (Splenda), saccharine, acesulfame K, Neotame, Stevia and Luo han guo. The latter is generally recognized as safe.

Fiber

Diet rich in fiber is very helpful for diabetic Muslims. Eating fiber on pre-dawn meals allows you to feel fullness for a long time. Fiber helps maintain blood sugar and protect against high blood pressure and heart disease; the major complications of diabetes in Ramadan. You can find fibers in fruits, vegetables, whole grains, nuts, beans, and legumes. Sometimes you may use fiber supplements. The available supplements include psyllium, methylcellulose, wheat dextrin, and calcium polycarbophil. However, such fiber supplements can cause bowel gases and bowel cramps that are not good in Ramadan. The advice is to take a small amount at the beginning and increase gradually watching out for the bad effects. Such practice is better to be initiated few months before Ramadan to test your tolerance. However, tolerance may vary with day fast.

fat

Diabetics, as well as healthy persons, should limit their intake of fat. Fat is the leading cause of heart disease and cerebral strokes. The unhealthy fat includes the saturated and trans fats. The saturated fat is found in cheese, milk, beef, and baked food. It is better to read the ingredients label list to find out the amount of each type of fat including the “partially hydrogenated oils.”  Skim milk and fat free diary product are highly recommended.

Tips to avoid having fat in your meals:

·         Liquid vegetable oil should replace the animal fat.

·         Pick up the lean cuts of meat.

·         Use olive oil instead.

·         Eat the foods baked broiled, grilled, roasted or boiled and never fried.

·         Fat-free or low-fat dairy food is available in the market. You can include them in your carbs count.

salt

The diabetic patient is advised to get away from salt as far as possible. Salt is the major risk factor for high blood pressure (hypertension). Frankly speaking, salt is an additional risk of hypertension with diabetes. Here you are some examples of food containing salts: canned meats, canned soups, and vegetables, cured or processed food. Also, it is better to avoid some additives including Ketchup, mustard, salad dressings and canned source. Pickled foods and processed meat should be avoided as well[xx].

B. water

Fluid intake is allowed during the nights of the Holy Month. It is the chance to have as much water as possible. Water, not the sweaty juice that matters. Drinking sweaty juice or carbonated fluids are not recommended. Both types of fluids will not provide your body with the necessary requirements of water. The diabetic Muslim, as well as the healthy, are advised to drink water as late as possible before the beginning of the fasting hours. It is also encouraged by Hadith that means “The morning meal is a blessed meal, so do not abandon it even if you take only a sip of water. Verily, Allah and His angels send blessings upon those who take the morning meal.” (Musnad Ahmed 11003, Grade Sahih).

Water drinking at the night of Ramadan should be encouraged at Iftar, before prayers and during the prayers as well. Suhoor the diabetic Muslim should drink ample water amount for digestion, absorption and balancing the water content of the body.

C. Exercise

Exercise is generally recommended for diabetic patients. However, in Ramadan exercise may lead to hypoglycemia. Exercise is better avoided before sunset breakfast because of the risk of low blood glucose. The diabetic Muslim should maintain normal levels of physical activity and avoid excessive exercise. When you are committed to the Tarawih prayer, you can consider the prayer as a part of your regular exercise. You should accept to break your fast if the excessive lowered your blood pressure. Patients on insulin therapy should measure their blood glucose before practicing. They are recommended to have sweet juice before the exercise; to be repeated every half and hour or every hour. Regular checking of the blood glucose is vital during exercise.

oral pill control during ramadan:

The choice of the oral pills during Ramadan is an individual issue. There are versatile variations in the glycemic response between the diabetic patients. The basic role is that the pills that increase insulin sensitivity have a low risk of hypoglycemia. On the other hand, the medications that enhance insulin secretion are not recommended because of the high risk of hypoglycemia.

Individual types of pills:

Ø  Metformin: it is the first line of management of diabetic patients. Metformin is very suitable for fasting in Ramadan. The risk of hypoglycemia with metformin is very low. The recommendation is taking two-thirds of the dose immediately before sunset breakfast and the remaining third is taking before the pre-dawn meal.

Ø  Glitazones (thiazolidinedione): such as rosiglitazone and pioglitazone are insulin sensitizers with a low risk of hypoglycemia. The dose need not change in Ramadan. However, the risk of hypoglycemia increases when they are used with insulin, sulfonylurea, and glinides. The unwelcomed effect of these agents is an increase in the body weight due to the enhancement of the appetite. Those patients who are going to use these agents for control of the glycemic state during Ramadan should initiate the medication at least one month before the Holy Month. The safety of the agents concerning the cardiac effect is neither proved nor confirmed. It is recommended that those diabetic patients who have or at risk of cardiac problems to avoid this group, just-in-case.

Ø  Sulfonylureas: most of them have a high risk of hypoglycemia. Chlorpropamide is absolutely contraindicated. The newly introduced sulfonylureas are known to have a low risk of hypoglycemia. They can be used by the diabetic Muslims in Ramadan. A Turkish study about the use of the new sulfonylureas in Ramadan was very promising. The use of glimepiride in a dose of 3 mg daily during Ramadan showed no changes in body weight, fasting plasma glucose, glycosylated hemoglobin, and the total cholesterol[xxi].

Ø  Short-acting insulin secretagogues: such as repaglinide and nateglinide have a short duration of action. In Ramadan, they can be used twice daily during the eating hours of Ramadan. Compared with glibenclamide, repaglinide showed a low risk of hypoglycemia and high safety profile during the fasting hours of Ramadan[xxii].

Ø  Incretin-based medication: these drugs act by mimicking the incretin hormone action. It is a naturally secreted hormone in our bodies. The main function of incretin hormone is to stimulate insulin secretion in response to meal. They should be used with diet and exercise to lower the blood glucose level. Exenatide, a member of such group, can be given before meals to decrease appetite and promote weight loss. It has no marked effect on fasting blood glucose level because of its short duration of action (2h). Liraglutide is given once daily. It is given not related to meals. Unlike exenatide, it controls fasting blood glucose level. individualized dose adjustment and tailoring are needed over a period of 2-4 weeks. When the diabetic Muslim is going to shift to these medications, he/ she should start at least one month before the Holy Month. The disadvantage of these agents is intolerability by the patients especially during the initiation of therapy. They cause nausea that refrains patients from continuing having the agent.

DPP-4 inhibitors agents are well tolerated by the patients and do not require dose adjustment. The member of these group works by increasing insulin hormone secretion after meals. However, they are less effective on hemoglobin A1c than the previous medications. There are not enough studies on such agent for diabetics fast in Ramadan as regard efficacy and tolerability. They are, however, a promising agent for use by diabetic Muslims during the Holy Month. They should be used with diet and exercise as well to impose the full glycemic control.

Ø  α-glucosidase inhibitors: individual agents are acarbose, miglitol, and voglibose. The mode of action is slowing down carbs absorption from the gut. They are not associated with independent risk of hypoglycemia. That is why this group is encouraged to be used during the Holy Month. However, these agents should not be used alone due to the null effect on fasting glucose. The tolerance of these agents is questionable. They cause gastrointestinal effects including flatulence. Patients who can tolerate such effects may continue seamlessly on the agents. The best way to minimize such effect (flatulence) is the use of modest doses and slow initiation of the medication depending on the patient tolerability. The diabetic Muslim should shift to these group of medicine at least one month before Ramadan to test for tolerability as well as the efficacy of the agent of glycemic control.

insulin injection control during ramadan

The principle insulin therapy in the diabetic patients in Ramadan is the use of intermediate- or long-acting insulin preparations. Short-acting insulin is administered before meals during the night of Ramadan. Proper basal insulin coverage all over the day can be achieved by one injection dose of insulin glargine given before the sunset breakfast meal. The peak action of the intermediate insulin is expected to be at pre-dawn meal providing adequate insulin covering to the meal. The NPH, Lente or Detemir insulin is given in two doses before the sunset breakfast meal and pre-dawn meal to provide adequate coverage of basal insulin all over the day. Frequent self-monitoring is needed to detect episodes of hypoglycemia.

Although the intermediate-acting or long-acting insulin would be sufficient, short-acting insulin is needed by many patients. The large caloric load of sunset breakfast obliges the patients to have short-acting insulin. The additional dose would be needed before Suhoor. Insulin lispro is recommended more than the regular insulin[xxiii]. Inulin Lispro has an ultrashort duration of action. The dose of inulin lispro should be tailored to the caloric intake. Therefore, the risk of hypoglycemia with insulin lispro is minimal.

The golden role in using insulin injections is dose adjustment with weight loss or gain that may occur in Ramadan. The incidence of hypoglycemia in patients with type 2 diabetes on insulin therapy is less than that in patients with type 1. Patients on insulin injections for a long time are at higher risk of hypoglycemia than those who have insulin injection for a short time because of beta cell failure.

insulin injection for type 1 diabetes:

The first suggested regimen for a patient with type 1 diabetes is taking 70% of the pre-Ramadan dose. The patient takes 60% of the dose as insulin glargine in the evening and 40% as an ultra-short acting insulin including insulin as part or lispro as two doses: one at Suhoor and one at Iftar[xxiv].

The second recommended dose is taking 85% of the pre-Ramadan dose. The patient takes 70% ultralente and 30% regular insulin given in two doses; one at Suhoor and one at Iftar[xxv].

The third regimen is taking 100% of the pre-Ramadan morning dose of the premixed insulin (70/30) at Iftar and 50% of the evening dose at Suhoor. However, premixed insulin in Ramadan is not advised by some authors.

insulin pump:

The advantage of the insulin pump over the long-acting insulin is that the insulin pump provides the body with basal insulin during the day. The basal insulin infusion is tailored for each patient. Self-administration of boluses of insulin with meals or at times of hyperglycemia guided by the mathematical support of the pump is a privilege. The patient can rely exclusively on the rapid-acting and short-acting insulin to ensure flexibility with precision. Therefore, it is believed that the risk of both hypo- and hyperglycemia can be managed effectively with the insulin pump more than with multiple insulin injections.

The management of hypoglycemia can be better achieved with the pump-based regimen than with multiple dose insulin injections. The pump offers downward adjustments or cessation of insulin release when hypoglycemia is detected. Such advantage is not provided by the multiple dose conventional insulin injections. Insulin continues to be released from the site of injection irrespective of the low level of blood glucose. Oral glucose intake is the only management to counteract the adverse effect of hypoglycemia with conventional insulin injection regimens.

Patients with type 1 diabetes can benefit from the insulin pump. They, however, should receive medical training and education before the Holy Month. Patient with type 1 diabetes should be otherwise metabolically stable and has no serious complications with the pump. Self-management is very important for a patient with type 1 diabetes. They should modify insulin infusion rates according to the home glucose monitoring.

The disadvantage of the insulin pump is that frequent self-monitoring blood glucose level is important to guard against pump failure or site failure. Failure of the pump or the site can lead to severe detrimental consequences.

hypertension and dyslipidEmia

Hypertension is one of the major macrovascular (big vessels) complications of diabetes. Most patients with type 2 diabetes have hypertension at one stage of their lifetime. Those diabetic Muslims who receive hypertension medication have the challenge to modify the antihypertensive medication as well.

Prolonged fasting hours in a hot weather is a high risk of dehydration and hence, hypotension. The dose of the antihypertension should be modified accordingly. Diuretics, the first line of management of hypertension, should be avoided in Ramadan. Diuretics promote dehydration and volume depletion. Angiotensin-receptor blockers and angiotensin-converting enzyme inhibitor are good alternatives. The medications for controlling cholesterol and triglycerides can be continued. Those who need more than one antihypertensive pill per day should discuss this issue with their physician. The duration of non-fasting hours is usually shorter than that of the fasting hours. This point should be considered as well.

Diet should be modified as well. Saturated fats and carbs should be modified according to cholesterol and triglycerides blood level. Pre-Ramadan control of the lipid profile is highly recommended 3-month before the Holy Month. Salt food should be considered as well for hypertensive patients. However, it is Muslim habit not to eat salty food during the nights of Ramadan to avoid thirst on the day of the Holy Month.

Summary of the regimen modification in ramadan

The following regimen modifications are for patients with type 2 diabetes who choose to fast in Ramadan: (the recommendation given in the following table is expert opinion i.e. not based on studies. These are subject to individual modification by physicians oriented with management of diabetic Muslim patients in the fast days)[xxvi]

Regimen Before Ramadan	Regimen during Ramadan	comments
Diet & exercise	Time modification. Modify physical exercise intensity. Adequate fluid intake.	The night prayer -Tarawih- should be included as a part of the exercise regimen.
Metformin 500mg three times daily.	Metformin 1000 mg at the sunset meal, 500 mg at the predawn meal.	Calories should be redistributed accordingly. in Gulf area, the main meal is Suhoor. So, the dose division is reversed.
Thiazolidinedione, α-glucosidase inhibitor, incretin-base therapies.	No modification is needed.
Sulfonylureas once a day.	The dose should be given before the sunset breakfast and modified according to the glycemic control and occurrence of hypoglycemia.	The frequent hypoglycemic attack is a reason for either modifying the dose, diet or not-to-fast.
Sulfonylureas twice a day.	The half the morning dose is given at the predawn meal (Suhoor), the usual dose is given at the sunset breakfast meal.	The frequent hypoglycemic attack is a reason for either modifying the dose, diet or not-to-fast.
premixed or intermediate-acting insulin twice daily.	·         Change to long-acting or intermediate-acting insulin for the evening dose; short or rapid-acting insulin with a meal. ·         The usual dose is given at the sunset breakfast meal and half the usual dose at the predawn meal. ·         Ensure adequate fluid intake.	self-monitoring blood glucose level should be carried out. The frequent hypoglycemic attack is a reason for either modifying the dose, diet or not-to-fast. The regimen should be trained on before the Holy Month.

 

Several precautions should be taken for safe fasting:

The patients with type 1 diabetes who insist to observe the fast should monitor their blood glucose level carefully to avoid alteration of the blood glucose level. The diabetic patient should avoid overeating during Iftar.

The fast should immediately be broken when the blood glucose level is as low as 3.3 mmol/l. and highly considered when the blood glucose level reaches a level of 4.4 mmol/l. Interruption of the fast is highly recommended when the blood glucose level reaches as high as 16.7 mmol/l. Patients with poor diabetic control should not fast. Those patients with type 1 diabetes with comorbid conditions including unstable angina, renal insufficiency, infections, uncontrolled hypertension and cerebral strokes should not fast at all. The patient should be compliant with the instructions given by the health care provider otherwise he/ she should not fast. The family and Imam should advise those non-compliant patients to follow the Muslim doctor advise and not risk their lives. Risking ones’ life is against the tradition of Islam. The meaning of the Holy Qur’an verse is “Spend in the way of Allah and do not cast into destruction with your own hands. Be good-doers; Allah loves the good-doers” 2:195. All the commandment of Allah including prayers and Haj consider the safety and capabilities of the Muslim. Allah exempts the weak and the incapable from doing the rituals. Allah considers an alternative or donation for certain rituals as well. The Muslim should discuss the issue of fasting with his/ her Muslim doctor and Imam. On the other hand, the physicians and Imam should consider the local traditions and the way of thinking of the Muslim in their location to direct the right message to them the right way. It is mandatory that both Muslim physician and religious counselor receive adequate information about the guidelines and guidance of the diabetic Muslim patients in Ramadan and for fast in the other days; voluntary fast.

Pregnancy of diabetic patients in ramadan

Risk of fasting of diabetic muslim ladies in ramada

Muslim pregnancies overlap with Ramadan in 75% of diabetic Muslim women. The risk to both the mother and the fetus is so high that pregnant women are exempted from fast during the Holy Month. Because of the spiritual enthusiasm, many Muslim women insist to fast the whole month or part of it. According to international Diabetes Federation in collaboration with the Diabetes and Ramadan International alliance (IDF-DAR), pregnant women are categorized as very high and high-risk groups. Very high-risk groups include pregnant women with pre-existing diabetes or diabetes during pregnancy (gestational diabetes) who are maintained on insulin injections or sulfonylurea pills. They are recommended not-to-fast; MUST NOT fast. High-risk groups are pregnant diabetic women (type 2, or diabetes during pregnancy) who are controlled perfectly by diet only or by metformin alone.

Pregnant Muslim women with pre-existing type 2 diabetes are different from pregnant Muslims with diabetes during pregnancy (gestational diabetes). Here you are some important facts that affect the decision of fasting of either woman.

Ø  Women with pre-existing diabetes are affected throughout the entire duration of pregnancy. Women with gestational diabetes suffer only a shorter duration in the second and third trimester. The latter group of pregnant ladies may cure from diabetes after labor.

Ø  The medication of the pregnant women varies as regards the risks during the fast. Incretins or thiazolidinedione are of low risk of hypoglycemia and safe during the fast hours. Most patients with diabetes are treated with insulin, metformin, and glibenclamide during pregnancy due to the safety of the drugs on the fetus and low risk of congenital malformations. However, insulin and glibenclamide have a high of hypoglycemia during the fasting hours of the Holy Month[xxvii]. The Muslim ladies are subject to break the fast frequently during the entire month.

Ø  Apart from hypoglycemia, hyperglycemia is associated with high risk for both the mother and the fetus. There are not confirmed data available to demonstrate such risk. For the safety of the mother and the fetus, the mother is recommended not fast.

management of diabetic Mulsim pregnant ladies in ramadan

From the religious point of view, the pregnant diabetic women have permission not-to-fast. They are expected to make up the missed days after delivery. Notwithstanding, most of the Muslim women (70-90%) choose to observe the fast[xxviii]. Most of them may not manage the whole month. Fasting alone after Ramadan is a challenge that most Muslim women refrain from taking it.

Most of the studies showed no harm of the fast on the healthy Muslim women and their babies (75). Other studies showed an increased risk of low birth weight and low placental weight in fasting healthy women. There are data from Uganda and Iraq relating learning disabilities and fetal exposure to Ramadan fast[xxix]. Due to the inconsistency of evidence and the religious license for women not-to-fast, the consensus is to categorize the diabetic women as a high-risk group.

Although fasting of the diabetic Muslim women is a personal decision, Muslim women should be empowered with the necessary information and skills for self-management during Ramadan. The Muslim women should realize that the health outcome of the fetus is not separate from the health of the mother. Those ladies with gestational diabetes are at lower risk of hypoglycemia especially when they are well controlled on diet or metformin before the Holy Month. However, these category is still at risk of high glucose level (hyperglycemia) after Iftar. So, they should achieve postprandial glucose targets guided by an expert team.

The recommendation for pregnant Muslim is not-to-fast. If the pregnant Muslim women insist to fast against the medical and legitimate advice, her decision should be respected. They should acknowledge the following:

-        Receive educational programs before the Holy Month and attempt to fast few days in Sha’ban as a test for their fast tolerance that would be expected in the Holy Month.

-        Having a qualified diabetes medical team for follow up and counseling during the Holy Month. Direct contact should also be available.

-        Regular checking of the blood glucose level: It is recommended to check your blood glucose before meals and 2 hours after meals. One to two measures at the beginning of the fasting hours to check for hypoglycemia. One check at midday. One or two checks before sunset. The lady should be oriented with the symptoms of hypo- and hyperglycemia. She should be ready to break the fast when the blood glucose level is below or above the recommended levels (< 4.0 mmol/l & >16.7 mmol/l).

-        Frequent episodes of low blood glucose level or high blood glucose level mandate cessation of fasting during the rest of Ramadan for the sake of the mother and the baby.

-        The medications of the pregnant lady should be adjusted according to the recommendations of the expert physicians.

 

alerta/ notificatioNs BEFORE RAMADAN[A2] 

1)       First alert/ notifications: TO BE SENT 8 WEEKS BEFORE RAMADAN

Pre-Ramadan assessment should be carried out with your physician 1-3 months before the Holy Month. Well-structured diabetes education program would be delivered to address most of the fasting issues. The physician would discuss the risks of hypoglycemia and hyperglycemia, the warning symptoms and signs and the means of monitoring blood glucose level. The health worker will learn you how to cope with such conditions including breaking your fast. You should have enough time to practice any change in diet or medications to cope with the new changes. Starting any new regimen needs time to get its full effect and maintain your blood glucose level in a plateau mode. Diabetic health education information should be intensely provided during these days to make you ready for fasting. You should keep your blood glucose level within the optimum level avoiding major complications and glucose level spikes. Unstable diabetic state risks your health. (150 words)

2)       Second alert/ notifications: TO BE SENT 7 WEEKS BEFORE RAMADAN

Low blood glucose level (hypoglycemia) below 3.3 mmol/l is very serious. You should react immediately. You feel dizziness, sleepiness, blurring of vision fatigued and sweating. The cause of hypoglycemia is too little food or high dose of insulin or sulfonylurea pills. Excessive exercise may risk low blood glucose. keep the diabetic card to alert others to help. Take a glucose tablet or sweetie juice at once.

High blood glucose level (hyperglycemia) above 16.7 mmol/l is the second most serious condition affecting type 1, type 2 diabetes and pregnant diabetic women. The symptoms develop slowly over days or weeks. Frequent monitoring of blood glucose level helps early detection. You may feel thirst, frequent pee, tiredness, and blurring of vision. You may have infections including thrush, bladder infection or skin infection. The cause of hyperglycemia is excessive eating, lack of exercise and missing medication dose. Drink plenty of water and seek medical attention. (150 words)

3)       Third alert/ notifications: TO BE SENT 6 WEEKS BEFORE RAMADAN

The consumption of complex carbs during the nights of Ramadan help maintain the blood glucose at a plateau level and keep your body weight constant while providing your body with the necessary energy. Complex carbs are rich in fibers that improve bowel motility and guard against constipation. Complex carbs contain vitamins, minerals as well. Bread and pasta made with whole grains contain more fibers. Whole grains and legumes protect your heart by lowering the risk of coronary attacks. Healthy food keeps you

Complex carbs include:

-        Dairy: Low-fat yogurt, skim milk.

-        Whole grain bread and pasta: contain fibers in addition.

-        Fruits and green vegetables: potatoes, tomatoes, carrots, strawberries, peas, radishes, broccoli, Spanish, apples, Pears, cucumbers, asparagus and dill pickles.

-        whole grains: buckwheat, brown rice, corn, wheat, barley, oats, sorghum and quinoa

-        starch vegetables: potatoes, sweet potatoes, corn and pumpkin

-        Nuts, seeds, and legumes: Lentils, kidney beans, chickpeas, soybeans, Pinto beans, and soymilk. (160 words)

 

4)       Fourth alert/ notifications: TO BE SENT 5 WEEKS BEFORE RAMADAN

Ramadan is the month to fast not to festive. Focus more on fasting as a worship to Allah. Focus on praying and recital of the Holy Qur’an. Thinking of the worshipping in Ramadan will deviate your attention away from food. This will help you during the fasting hours as well as overnight time.

Consider drinking much water overnight to restore the water loss during the day. Carbonated drinks are not recommended as they disturb digestion and absorption of food and cause annoying abdominal distention. Exercise should be tailored to your health condition and capabilities. Tarawih praying should be considered as a part of the exercise. In between meals, eat many fruits that contain vitamins, mineral, fibers and other nutrients. The recommended fruits are apples, pears, organed, melons, peaches, bananas, and nectarines. A mixed fruit salad dish is a good snake dish that helps promote your good carbs intake.

 

30 short catchy lifestyle recommendations Before Ramadan in bullet points.

We will use these messages 30 to 1 day before Ramadan. We will use one message per day. These messages have to include information that is a must to know before Ramadan.

It is important to organize these short messages in a logical way. That’s why I have moved your Day 17 to be the first message 30 days before Ramadan (because we cannot say 13 days before Ramadan that the patient should have a pre-Ramadan assessment, health education and diet counseling at least one month before the Holy Month.). Could you please go through all these short messages and organize/ rewrite them in a logical order?

Also, if I am a Muslim man, the messages directed to a pregnant diabetic person is not relevant to me. Could you please make sure that every day there is a message that applies to all Muslim people and alternatively say “Note: Pregnant women…. “. The same applies if you write a message directed only to a certain group of diabetic people (e.g. Type 1 diabetic), for that day you should also write something for Type 2 diabetic, so that everybody feels like they get a message relevant to them.

Day 30  

General

·         It is important to have a pre-Ramadan assessment, health education and diet counseling at least one month before the Holy Month. Visit your physician to carry out such assessment.

·         The Ramadan-focused educational program provided by your health caregiver enables you to maintain and improve your glycemic control during and after the Holy Month. Most of the patients who followed the diabetic education program were able to fast more than 15 days of Ramadan.

Day 29

General

·         You, diabetics, have permission to eat during the Holy Month. It is not a sin for you. Rather a grace and mercy of God. Discuss the permission of not-to-fast with your Imam and your Muslim physician. N.B.: Most non-Moslem physicians are aware of the proper management of diabetic patient in Ramadan.

Type 1 diabetics

·         It is better not-to-fast unless you have been stable for a long time (3 months) before the Fasting Month. Review the risk category with your physician.

Pregnant diabetics

·         It is better not-to-fast. Pregnant ladies with diabetes only during pregnancy (gestational diabetes) are at lesser risk of complications than those who have diabetes before pregnancy (pre-existing diabetes).

day 28

General

·         Test your blood glucose level before meals and two hours after meals. Test at the early hours of the day, at noon and before Iftar. Make sure that your blood sugar level is stable and within the optimum level before going through the Fasting Month.

Type 1 diabetes

·         Self-monitoring blood glucose level (SMBG) is an essential educational issue for diabetic Muslims with type 1 diabetes. You should practice SMBG before Ramadan and under the supervision of your healthcare provider.

Pregnant diabetic

·         Make sure that your blood glucose level is maintained within the acceptable level before going through the Fast Month.

Day 27

General

·         Carry simple sugar with you wherever you go during the day. Make it your habit before the Fast Month. Be ready to break your fast when you have the symptoms of hypoglycemia.

·          You should carry also diabetic alert ID with all the essential information for the responders to help you.

Day 26

General

·         Break your fast immediately if the blood glucose level is below 3.3 mmol/l (60mg/dl) or above 16.7 mmol/l (300 mg/dl) and correct the blood glucose level.

·         You have a low blood glucose level when you feel unwell, disoriented, confused or excessive sweating. Immediately, eat simple sugar or drink sweet juice.

·         You have a high blood glucose level when you may have thirsty, headaches, blurred vision, frequent micturition, and altered consciousness; in severe cases. You need to either take the missed dose, reduce your carbs meal, and drink amble water. Very high blood glucose level (>300 mg/dl) mandate hospital visit.

Pregnant diabetics

·         You should discuss with your obstetric physician how to ensure the safety and vitality of your baby. Checking your baby is subject to the schedule protocol recommended by your obstetric physician.

Day 25

Insulin-Treated patient (type 1 & type 2 diabetics)

·         Insulin therapy should be discussed with your physician before the Holy Month to adjust the type and the doses. You should follow the guidelines of your physician carefully. Sustained blood glucose level with the new regimen is mandatory before going through the Fast Month.

·         Intermediate and long-acting insulin are suitable for diabetic Muslims in Ramadan. Moderate eating habits as well. You should have the skills to monitor your blood glucose level by yourself. You should receive the necessary education to manage diabetic emergency promptly.

Type 2 diabetics

·         Modify your oral pills with your doctor’s help. New anti-diabetic medication increases insulin sensitivity with low risk of hypoglycemia. Avoid the old generations of sulfonylurea.

Day 24

General

·         You are special and so does your illness. Do not follow the regiment of your peers. Discuss with a physician first.

Day 23

General

·         Drink more water and eat more vegetables and fruits. Abstain from smoking as well.

Day 22

General

·         The six points you should learn pre-Ramadan are: 1- when to break the fast; 2- your risk category; 3- how to monitor your blood glucose; 4- receive professional fluid and dietary advice; 5- receive exercise advice; 6- consider medication adjustment or change with your physician.

Day 21

General

·         Exercise is important to improve your diabetes state. You should maintain on a regimen that is suitable for you under the supervisor of your healthcare giver.

·         Drink amble water after exercise to avoid dryness specially in hot weather.

Pregnant diabetics

·         Exercise should be reconsidered and modified as your pregnancy progresses. Pregnant ladies in the last trimester are encouraged to walk unless otherwise stated by your obstetric physician.

Day 20

Type 1 diabetics

·         Do your best to make your blood glucose level stable during this month before the beginning of Ramadan. Keep your commitment to the diet and the insulin regimens within the optimum range. Continue checking your diabetic status.

Pregnant diabetics

·         Pregnant diabetic women are at high risk of hypo- and hyperglycemia during the Holy Month. Gestational diabetic women are less likely to have diabetic complications when they follow the proper management plan. (what [A3] is the proper management plan? Can we refer here to the article Pregnancy of diabetic patients in Ramadan or recommend to have this plan made in collaboration with their doctor?)

 

day 19

General

·         Enjoy 2-3 servings of whole grains food. No risk of weight gain. Low level of cholesterol. Keep complex carbs at pre-dawn (Souhour) meal.

Day 18

General

·         Diet with high-fiber content maintain your body weight and promote the bowel function.

Day 17

General

·         You can attempt voluntary fasting 2-3 consecutive days and test your diabetic state during fasting following your already planned regimen. You can break your fast in Sha’ban without blaming yourself.

·         If you have any complications during fasting, you should discuss such complications with your treating doctor. Try to consider regimen modifications as regard diet or medications dose. If the modifications are major and needs time to be established, it is better to consider not-to-fast.

·         Remember that most of the new oral diabetic pills needs 3 months to establish normal glycemic control and many of them have some untoward effects. If you have intolerable effects during fasting attempts, you should discuss the effects with your doctor. 

Day 16

General

·         Maintain on whole wheat food such as brown rice, quinoa, oats, bread, and pasta. Keep away from white bread, regular pasta, white rice or processed food made from refined flours.

Day 15

General

·         Reduce the salt intake to the minimum. It will increase the sense of thirst in Ramadan. Salt risk increase of your blood pressure.

Day 14

General

·         Minimize fat and sweet intake to the very minimum. The temptation in Ramadan will be great. Therefore, you should be psychologically ready to resist such temptation with ease.

·         Diet regiment should be fully committed on.

Day 13

General

·         You should have fruits, vegetables, simple carbs with fiber, protein, vitamins, and minerals during the nights of the Holy Month. They supply your body with the needed nutrients including energy, vitamins, and minerals.

 

Day 12

General

·         Slices of fruits are very healthy snakes in between meals. They help improve your carbs intake and provide you with energy for prayer and recitation of the Holy Qur’an.

Day 11

General

·         Consult your regional physician to give the appropriate advice according to your region and culture. The eating traditions differ from one place to the other.

day 10

General

·         Check for your blood pressure and renal function. You still have time to control your blood pressure, if it has not been controlled yet. Avoid diuretics whenever possible. Losing water during the fasting hours has a risk of dehydration and it is not recommended.

·         If your renal function is stable and not affected, you have a good chance to fast in Ramadan.

Pregnant diabetics

·         Pregnant ladies in the last trimester should be sure that the blood pressure is either controlled in pre-pregnant diabetics or not present at all in gestational diabetic ladies.

·         Newly developed hypertension or uncontrolled blood pressure of previously controlled blood pressure should mandate immediate control and not-to-fast should be considered.

·         Development of any obstetric complications should make you reconsider fasting. The risk of the obstetric complications on your diabetic condition and fasting should be thoroughly discussed with your physician. Not-to-fast is better is for your safetly.

Day 9

General

·         Check your diet regimen. It is time to be more strick on the proper diet regmen for diabetic patients as it will be in Ramadan. If you are still not f to fully committee to the diabetic diet, you should begin now.

Day 8

General

·         You should remember that most of the Muslim scholars agree that taking insulin injection or taking blood sample during the day of Ramadan will not invalidate your fasting. It is better to prepare yourself for doing both during the day of Ramadan without hesitation if necessary.

·         Discuss this issue thoroughly and extensively with your Imam. You may need to have an extra insulin dose and IV fluid during the day of Ramadan to manage hyperglycemia. Blood test during the day is important to check for hypo-or hyperglycemia. Refraining from blood testing may interfere with your regimen and risk your life.

·         If you are still in doubt psychologically, you should discuss this issue with another Imam or your authenticated Muslim institute for Fatwa in your country.

 

Day 7

General

·         Avoid skipping meals or medication dose. This point will be so critical in Ramadan. If you skipped a meal or a dose, you should consider breaking the fast for your safety, otherwise, you should be careful.

·         Use a reminder for maintaining regular meals and medication. The skipping meals and medications will me minimized.

Day 6

General

·         It is time for final evaluation of your health condition and making final decision before the beginning of the Fast Month.

·         Optimization of the Ramadan-specific treatment regimen and management plan for each individual patient is essential to deliver the best care. If you have ups and downs during the few weeks, you should consider not-to-fast for your safety.

Type 1 diabetics

·         If you have diabetic complication such as severe hyperglycemia and/ or ketoacidosis, you should consider not-to-fast.

Pregnant ladies

·         If you have any risk for your health or your baby health, you should not fast for the safety of both of you and your baby.

Day 5

·         Elderly Muslims suffering diabetes for a long time will have comorbid conditions that represent an impact on the safety of fasting and a challenge to diabetic management. They are adviced not-to-fast. Perfect assessment of their general condition and the morbidities as well as the cognitive function is important for the decision making.

Day 4

·         Consult your religious leader -Sheikh or Imam-  as well as your Muslim physician in your region or locality seeking for unification with your Muslim doctor on whether you are going to fast or exempted. Not-to-fast with a permission of Allah is not a sin. You obey Allah when you don’t fast because of your illness.

·         When you are at high risk during fast, you must understand you are rewarded exactly the same as those who fast without any decrease. You need not feel guilty or sin.

Day 3

·         Ramadan for fasting not festive.  Eat healthy and balanced food. Drink more water. Exercise less. Keep away from food loaded with saturated fats.

Day 2

·         Exercise nearly 2 hours after the sunset. Lengthy praying is considered an exercise. No extra-activity during the day of Ramadan. Exhaustive physical labor is an extra permission for not-to-fast.

Day 1

·         Date and milk are good for breakfast and do not cause spikes of your blood glucose level. It is also Sunnah. Take date before Maghrib prayer and during the prayer as well.

       

recipe section

The proposed videos have been sent in a separate file to a separate project

 

During ramadan (30 days during ramadan)

30 short catchy texts (150 words each): 1 daily recipe and 1 life recommendations. (the daily recipe will be sent as video links in the separate project according to your preference)

We will use these messages 1 to 30 day during Ramadan. We will use one message per day. These messages have to include information that is important to know during Ramadan/ it is a reminder to patients about things that they probably already know and should not forget to remember/apply now during Ramadan.

Please see the comments from the section 30 short catchy lifestyle recommendations before Ramadan. Here (during Ramadan) please imagine that you are a Muslim patient in the period of Ramadan. It does not make sense to get recommendation on what you/ the patient was supposed to do before Ramadan. Therefore, some of these 30 messages here below can be moved to the section 30 short catchy lifestyle recommendations before Ramadan, as they will make more sense there.

+ the recommendations need to be ordered in a logical/ chronological way for during Ramadan.

 And again, I would like to make sure that all diabetic patients get an appropriate & useful message every day (e.g. Type 1, Type 2, pregnant women, etc.)

Day 01	General	-        when you feel drowsy, sweaty and disoriented take 15gms simple regular (non-diet) sugar immediately within 15 min. Your fast should be broken for your safety. -        Eat dates on breakfast with a cup of milk and go to Maghrib Prayer. -        It is a Fast Month, not festive. Eat adequate and balanced diet as your usual days before Ramadan.
Day 02	General	-        Your meal should be as follows: carbs: 45%-50%; protein: 20%-30%; fat (mono- and polyunsaturated) < 35%; saturated fat: <10%.
Day 03	General	-        Avoid Zalabia, fried samosa, greasy pasties, and smoking.
	Insulin-managed patients	-        The concepts of glycemic index, carbs count, and I:C are useful tools to estimate the carbs amount of your food and your rapid-acting insulin dose required.
Day 04	General	-        Your Tarawih Prayer should be considered as a part of your exercise regimen. -        Drink amble water before, during and after prayer. Keep sweets in your pocket, just-in-case you have symptoms of low blood glucose (hypoglycemia).
Day 05	General	-        Whole grain food like whole grain bread and pasta are more preferred than the processed food.
Day 06	General	-        Olive oil is much more preferred than butter and margarine. The latter should be either totally avoided or restricted.
Day 07	General	-        Use fresh fruit as daily dessert instead of sweets and candy. -        Eat poultry, eggs, cheese but not meats.
Day 08	General	-        You may consider checking your diabetic status with your physician. Remember to report the level of the blood glucose you have measured in the past week.
	Pregnant diabetics	-        Pay a visit to your obstetric caregiver or your GP for checking the health of your baby. Discuss the next follow up visit, if needed. If you are in the third trimester, check your blood pressure regularly. You can use the home devices. Consult your health caregiver if your blood pressure exceeds 140/90 mmHg on more than one occasion.
Day 09	General	-        Measure your blood glucose before exercise or activity; recheck every 30-60 min; eat 15gms of carbs when necessary.
Day 10	Type 2 diabetics	-        Exercise is good for type 2 diabetes patient as it helps glycemic control and either maintain your body weight or help reduce it.
	Type 1 diabetics	-        Exercise is vital for type 1 diabetic patients as it help prevent the long-term complications. -        Exercise help reduce the insulin need for your muscles.
	Pregnant diabetic	-        Ladies in the third trimester are required to walk and practice mild exercise to facilitate delivery later.
Day 11	General	-        When you are ill, common cold, flu or cough, do not stop your anti-diabetic medication; eat more calories; consult your healthcare provider.
Day 12	General & Type 1 diabetics	-        Self-monitoring blood glucose is a good practice against hypoglycemic episode especially in Ramadan. This point is specifically important for type 1 diabetics.
Day13	General	-        Remember your meals and the calories well; missed meals cause hypoglycemia. You should not neglect the pre-dawn meal at all. Take the same amount of carbs that suites your medications, no more no less.
	Type 1 diabetics	-        Self-monitoring your blood sugar is essential to detect hyperglycemia. You can check for acetone in either blood or urine as well. If acetone is there, you should consult your health caregiver immediately.
Day 14	General	-        When you modify your diet and calories, your anti-diabetic medication should go hand-in-hand with the change in foods. You should discuss with your health caregiver for sure.
	Type 1 diabetics	-        When you are going to reduce or increase your meal, your short or ultra-short insulin injection should be adjusted accordingly. You can get benefit of the dose flexibility of short/ ultra-short insulin. -        Those on insulin pump should make sure that the pump is responding properly to meal caloric variability and there is no malfunction. Frequent self-monitoring of blood glucose level is recommended.
Day 15	General	-        Keep diabetic Identification card, bracelet, or necklace with you. The diabetic ID card could be a lifesaving in emergency cases.
Day 16	General	-        Adjust your diet, insulin, and/ oral pills with your physical activity. By the mid of the month, the activity tends to slope downward. The diet and medications should be modified accordingly. Vigorous activity or exercise is not recommended on the day of Ramadan for all diabetic categories.
Day 17	Type 2 diabetics	-        The new oral anti-diabetic medications may cause nausea, stomach upset, or bloating. If such untoward effects are intolerable, you should discuss with your physician many options including treating the untoward effects, modifying the doses, or changing the medication. You may be asked to not-to-fast.
Day 18	General	-        Remember to break your fast immediately if the blood glucose level is below 3.3 mmol/l (60mg/dl) or above 16.7 mmol/l (300 mg/dl) and correct the blood glucose level. -        When your blood glucose level is low, eat simple sugar or drink sweet juice. -        When your blood glucose level is high, you need to either take the missed dose insulin dose, drink amble water. Check for your acetone in blood or urine. Very high blood glucose level (>300 mg/dl) mandate hospital visit.
Day 19	General	-        Visit your health caregiver for general evaluation of your diabetic state. Remember that frequent alteration of your blood glucose level may raise the need to stop fasting the rest of the month. For most of the diabetics, 15 days of Fast is a success.
	Pregnant diabetics	-        You may consider visiting your obstetric physician of checking the baby health and vitality. If you did not visit your doctor previously, it is recommended to consider visiting your doctor now.
Day 20	General	-        When you are in Masjed for I'tikaaf   (اعتكاف), you should stay in a well-aerated place, air-conditioned places are recommended. -        Muslims who share I’tikaaf with you should be aware of your illness to help you in case of emergency. -        Remember to drink amble water at night and at Souhour.
Day 21	General	-        When you are committed to night prayer Thjud (تهجُد), remember to drink water between the prayer and eat sweets. You may stop when you feel tired or drowsy. Your fellow men should be aware of your illness to help you when needed.
Day 22	General	-        Date is rich in fructose and fiber. Dates will not raise the blood glucose at Iftar. It is better to have some when you go to Mosque for Maghrib prayer. -        Dates are rich in vitamins and minerals; with milk, they constitute a full meal.
Day 23	General	-        Your body weight should be maintained during the month of Ramadan. Only a small sector of type 2 diabetes is allowed to reduce weight under specialist supervision.
Day 24	General	-        Keep mentally oriented that you may break the fast when you have hypoglycemia, hyperglycemia, diabetic ketoacidosis, or dehydration. You did a great job so far. Don’t be press hard on yourself. Those who follow the permission of Allah not-to-fast, are obedient as well.
Day 25	General	-        Now you have completed 24 days Fasting. Most of the diabetics can complete fasting the whole Month. However, if you are confronted with frequent complications during the past days, it is better to consider cessation of fasting the rest of the day. Discuss with your physician and Imam.
Day 26	General	it is the Night of Power, laylat alqadr (ليلة القدر) as believed and practiced by most Muslims. -        Avoid crowded and ill-aeriated places for night prayer this night. Keep drinking water and eating dates or any sugar source between the prayer. You company should be with you to provide help when you need.
Day 27	General	-        Follow the meal regimen per calories according to your locality and region. The meals content can be modified according to food available in your place. -        It is not the time to try meals from other locality or culture unless you know the caloric content.
Day 28	General	-        Tomorrow or the day after tomorrow the feast will begin and the health services will be restricted to the emergency departments. It is better to consider: -        Final check of your diabetic status with your physician. You may be so exhausted to complete the last day. No harm. Otherwise, you would proceed. -        Keep a mean of communication with your physician or other health services at hand to be used during the feast if needed e.g. phone number, emails, internet communication…etc. -        Make sure that the diabetic alert ID is always with you and within the reach of the first responder. -        Discuss the diet and medication regimens during the three days of the feast with your physician. Those who uses pills, should discuss the possibility of modifying the dose according to the habit of eating.
	Type 1 diabetics	-        The medical regimen should consider the temptation of eating more sweets and fatty food. Short/ ultra-short acting insulin and insulin pump would be attractive alternative.
	Pregnant diabetics	-        If you did not submit to medical assessment during the previous days and you are still fasting, it is better to visit your diabetic as well as obstetric physician for pre-feast assessment. Make sure that the baby is developing well, and your blood pressure is within normal range. -        Keep a mean of communication with your obstetric physician or the related health service at hand if needed e.g. phone number, emails, internet communication…etc..
Day 29	General	-        Congratulation, you are almost done. You would clear the challenge within few hours. Change nothing of your regimen. Keep sticking to your regimen to the last minute. -        Keep checking your blood glucose level during the day. When the next day is no fasting, you will be ready to return to the pre-Ramadan regimen. -        Cautious, not to indulge in excessive sweet and fatty food intake. Most of the serious complications occurs in the two days before the feast and at the feast because of violation of the diet regimen.
Day 30	General	-         Today is the last hours of fasting. We wish your Fast and Payer are accepted and rewarded by Allah. Continue the Ramadan regimen in the morning and take your medications as usual at Breakfast. -        There will be no Souhour. So, you will start the pre-Ramadan regimen in the morning. and Keep checking your blood glucose level more frequently. Make sure that the food and the medications keep the blood glucose level below the 200 mg/dl and above 60 mg/dl. -        Be careful not to have major fluctuation of your blood glucose level when you are reverting to the pre-Ramadan regimen.

 

Alerts/ notifications: daily reminders for email, SMS, and Twitter. (±150 words each)

These are ok.

-        Day1:

 Ramadan is one of the five pillars of Islam that is incumbent on every Muslim, adult and capable. The sick, travelers, aged or pregnant are exempted. The Holy Qur’an says “O’ Believers, fasting is decreed for you as it was decreed for those before you; perchance you will be self-restraint [A4] (2:183) (Fast) a certain number of days, but if anyone of you is ill or on a journey let him (fast) a similar number of days later on; and for those who are unable (to fast), there is a ransom the feeding of a needy person. Whosoever volunteers good, it is good for him; but to fast is better for you if you but knew” (2:184). Muslim scholars condemn jeopardizing your health. Legitimate excuse allows you full rewarding. The final decision should be shared between your local Muslim physician and your Imam. Your previous clinical condition would enlighten the answer.

-           Day2: Diet regimen in Ramadan aims at controlling and optimizing your blood glucose level. those who are type 2 diabetes and overweight are to channel the strength and discipline for improving their lifestyle and lose weight. You need to consume adequate calories from sunset to dawn to prevent low blood glucose level (hypoglycemia). You, also, should distribute the carbs intake equally among meals to prevent glucose spikes after meals. Your diet should consider other associated illnesses such as hypertension (decrease salt) and dyslipidemia (reduce fat). You should stick to the pre-Ramadan recommendation and education received from your physician and health worker. Drink more fluids at night especially water to avoid dryness (dehydration) during the day. It is better to avoid snakes between meal to avoid long periods of hyperglycemia after meals. Eating fast leads to overeating and weight gain. Eat slowly.

Day3: From sunset to dawn in the Holy Month of Ramadan, avoid these unhealthy habits and attempt the alternative:

Avoid eating more than 1500 cal. High calories increase the blood glucose level after a meal and risk overweight.

Avoid eating a large amount of processed food. They risk high blood glucose level.

Avoid desserts with sugar and butter.

Avoid snakes of ample amount of fatty food between Iftar and Suhoor. Eat vegetables and fruits with moderate amounts.

Eating slowly and chewing carefully help decrease the amount of the meal. Satiety signals need about 30 min to reach your brain.

Stick to Sunnah: early breakfast and late Suhoor. This regimen helps maintain your blood glucose level when the fasting hours are prolonged.

Avoid simple sugars at Suhoor. Instead, consume complex carbohydrate. Complex carbs like whole grain give you the feeling of fullness, steadily increase your blood glucose level all over the day (guarding against hypoglycemia) and improve the colon motility; due to the high fiber content.

Avoid fried food with trans-fat margarine or oils rich in saturated fat. Alternatively, use dry frying using a non-stick pan or non-stick food sprays for preparing healthy food. You can eat grilled or baked meat, chicken or fish and keep the same taste and flavor.

Changing the physical activity and the sleeping pattern risk high blood glucose level. practice a little. Include Tarawih praying into the exercise program.

Water is essential for your health and for digestion. So, drink ample amounts of water overnight.

Day4:  Pre-dawn food (Suhoor): let it be as late as possible. Wholesome meal gives you prolonged energy during the fasting hours. Food containing complex carbs including whole wheat, oats, beans, and rice are advised. Fiber-containing foods are raw and unpeeled fruits and vegetables. Water and fresh fruit juices maintain water and salt levels inside your body. Caffeinated drinks increase water loss by micturition leading to dryness (dehydration).

Sunset breakfast: following Sunnah, breaking your fast with a date, water and milk (skim) regain your body sugar, water, and salt to the optimum levels. Diabetic Muslims can pray Maghrib safely.

Dates are:

easily digested,

giving fullness sensation thus, avoiding overeating,

rapidly restore body nutrients,

prevent constipation.

Avoid:

Fried samosas, chicken, spring rolls and potato chips.

High sugar and fat food: zalabia, Gulab jamun (India), badam halwa and barfi (India & Gulf).

High-fat foods: oily curries & greasy pastries.

Day5: Diabetic Muslims with type 2 diabetes have a good opportunity during Ramadan to attempt weight reduction. Weight reduction help control your blood glucose level and decrease or delay the complications. The optimal target to steadily reduce your weight is 0.5 – 1kg per week. This gives you a chance to reduce 2-4 kg per Ramadan. To safely achieve this goal the caloric intake should be maintained within a specific range for height and gender. The caloric intake should be proportionately distributed between Iftar and Suhoor.

The caloric target for men, to maintain body weight, is 1800 – 2200kcal/d.  Women <150 cm should target 1500 – 2000 kcal/day while taller women should target 1500 kcal/day. To reduce weight, diabetic Muslim should step below these figures.

Proportionate distribution of calories should be 30-40% of the total calories of the day at Suhoor and 40-50% of the calories at Iftar. 10-20% of calories are preserved for snacks.

Day6: -Carbohydrate should comprise 45-50% of your meals; protein (legumes, fish or poultry) 20-30%; fat (mono and polyunsaturated fat) < 35%; saturated fat should be <10%.

- Avoid sugary desserts. Moderate amount of healthy dessert is permitted including a slice of fruit.

- Choose whole grain carbs rich in fibers. Vegetables-carbs, whole fruits, low-fat yogurt, and dairy products are encouraged. Wheat flour and starch such as corn and white rice and potato are not advised.

- Ample water and non-sweetened beverages are advised between the meals. Plenty of water help maintains adequate hydration. Avoid sugary drinks, canned juice, and caffeinated drinks.

- Fasting more than 10 hours mandate late Suhoor.

- Save adequate amounts of protein and fat for Suhoor. They do not cause glycemic spikes after meals. They cause satiety for long hours.

- snakes may include one piece of fruit, nuts, and vegetables within the range of 100-200 cal.

Day7: Rigorous exercise and exhaustive activities are not advised during the day of the Holy Month. During fasting, exhaustive activities raise the risk of low blood glucose level (hypoglycemia) and dryness (dehydration). However, diabetic Muslims are encouraged to take regular light-to-moderate exercise during the Holy Month. Avoid exercising in the hot weather and during the long days of 10-hours fasting. Going to the mosque and praying can be considered as an acceptable activity and should be included in your exercise program. The nights of the Holy Month are the very suitable time for practicing and exercising. You can have the needed amount of water and sugar before and after your routine to avoid hypoglycemia.

In Tarawih prayers the Muslim bows, kneel and rise. This movement can be considered as a part of your daily exercise routine. You should have some sugary juice before and in-between the prayers to avoid hypoglycemia during praying.

Day8: When to break the fast?

You should learn the symptoms of hypoglycemia and hyperglycemia that risk your health. You should be mentally prepared to break your fast when either condition is detected. When your blood glucose level is low (<4.0 mmol/l, 70 mg/dl) you may feel trembling, sweating or chills, palpitations, hunger, drowsiness, confusion, and headache. Sleepiness and sweating are very prominent symptoms. When your blood glucose level lies between 3.9-5.0 mmol/l (70-90 mg/dl) you should be cautious and measure your blood glucose level hourly. The effect is rapid within hours or minutes. So, you should break your fast immediately with sugary fluid.

 When your blood glucose level is high (>16.6 mmol/l, 300 mg/l) you may feel thirsty, hunger, frequent urination, fatigue, confusion, nausea/ vomiting and abdominal pain. The high level of hyperglycemia should be individualized. So, you should consider direct contact with your health care provider or your physician.

Day9: Proteins and fat in Ramadan:

Protein intake should be 1.2g/kg/day (20-30%). Protein keeps lean body mass. Eating protein at Suhour promotes satiety during the day. The recommended protein sources are fish, skinless poultry, dairy, nuts, seeds, and legumes. You should avoid protein rich in saturated fat: beef and lamb because it increases the risk of diabetic complications.

Fat consumption increases the risk of cardiac and blood vessel complications. Fat consumption should be <35% of the total caloric intake. You should stress on food containing polyunsaturated and monosaturated fatty the acids including olive oil, vegetable oil or blended oil. Oily fish such as tuna, sardines, and salmon are recommended as a source of Omega-3 fatty acids. Food with saturated fatty acids should be <10% of your caloric intake. It is found in red and processed meat: beef, lamb, hot dog, salami, luncheon meat. Avoid margarine, butter made of partially hydrogenated oil.

Day10: Here you are an example of a recommended meal for sunset breakfast:

v  1 cup of vegetables

v  4 oz. of lean protein: skinless poultry

v  1.5 cup of whole grain rice.

v  0.5 cup of beans or lentils.

v  2 teaspoonful of olive oil: use in cooking or added on salad.

v  1 glass of low-fat milk (skim).

v  1-3 dates: immediately after Azan. With milk is good before Maghrib.

v  1 small slice of watermelon: good source of fiber and water.

This meal provides 770kcal, 45% carbs, 20% protein and 35% fat.

Daily Caloric intake	1200Kcal	1500Kcal		1800Kcal		2000Kcal
Sex and Hight	women <150 cm tall	women <150 cm tall	women >150 cm tall	women >150 cm tall	men	women > 150 cm tall & men
Effect	reduction	maintenance	reduction	maintenance	reduction	maintenance

You should adjust the calories according to your personal daily caloric target. Caloric target is adjusted as per weight and sex:

                

-        Day11: Milk is the favorable drink during the Holy Month. By drinking milk at Iftar, you are adherent to the teachings of Prophet Mohammed (PBUH). Milk is a good and natural source of simple carbohydrate. So, it is recommended to drink milk at Iftar at once to raise your blood glucose level. One cup of a serving of milk or ¾ cup of a serving of yogurt contains 12 gm of carbs. When you have fat-free milk the amount of carbs does not change. Skim milk is recommended. Moreover, milk and yogurt are rich sources of protein and calcium.

Dates are also advised by Sunnah. Dates will not cause your blood glucose level to spike at Iftar. Dates contain very low fat and rich in proteins and vitamins including vitamin B, A, and C. Dates contains fructose sugar. It is safely digested. Many studies prove the safety of dates consumption for diabetics in Ramadan.

-        Day12: Dates, fresh and dried, are mentioned more than once in the Hadith of the Messenger of Allah. Dates contain a high amount of fructose. This sugar is similar to glucose. However, fructose can enter the cells without the help of insulin. It is considered as a good alternative to glucose. Eating dates at Iftar will not raise the blood glucose level. Therefore, the diabetic Muslim will not suffer the spikes of hyperglycemia that usually follows the breaking of the fast. This help maintains a plateau blood glucose level. the diabetic Muslim can go safely to the Maghrib Prayer with high safety profile. Notwithstanding, it is advisable to have about 10 mg of sugar or sweets in ones’ pocket, just in case. In the mosque, people diffuse dates for everyone before prayer. It is Sunna to break your fast before praying and not to delay breaking fast. Dates contain fiber, vitamins as well.

Day13: caloric-guided meals

Ramadan nutritional application toolkit of 1200 Kcal/day for Middle East patients:

                300 – 480 Kcal (Suhoor: 30 -40%):

·         Beans: 0.3 cup

·         Yogurt: 1 tub; with low-fat milk

·         Cheese: 1 oz./ 1 slice; low salt for hypertensives

·         Small olive: 5

·         Wholegrain bread: 1 thin slice.

·         Tomato and cucumber salad plus 1 egg.

·         Water and unsweetened drinks; ample water intake is encouraged.

120 – 240 Kcal (snake 1: 10 – 20%):

·         Dates: 1-2

·         Water and unsweetened drinks; ample water intake is encouraged.

480 – 600 Kcal (Iftar: 40 50%):

·         Dates: 1-2

·         Salad: tomatoes, cucumber & greens with lemon or vinegar dressing; 1 medium bowl.

·         Soup: grilled or broiled chicken or lentil or meat; 4 oz.

·         Cooked vegetables: 1 cup

·         Rice: wholegrain rice; 1 cup

·         Whole fruit: 1 small piece

·         Water and unsweetened drinks; ample water intake is encouraged

120 – 240 Kcal (snake 2: 10 – 20%):

·         Walnuts: one handful; 3 tablespoons.

·         Water and unsweetened drinks; ample water intake is encouraged

-        Day14: caloric-guided meals

Ramadan nutritional application toolkit of 1500 Kcal/day for Middle East patients:

                450 – 500 Kcal (Suhoor: 30 -40%):

·         Beans: 1 cup

·         Yogurt: 1 tub; with low-fat milk

·         Cheese: 1 oz./ 1 slice; low salt for hypertensives

·         Small olive: 5

·         Wholegrain bread: 1 thin slice.

·         Tomato and cucumber salad plus 1 egg.

·         Water and unsweetened drinks; ample water intake is encouraged.

130 – 300 Kcal (snake 1: 10 – 20%):

·         Dates: 1-2

·         Water and unsweetened drinks; ample water intake is encouraged.

600 – 750 Kcal (Iftar: 40 50%):

·         Dates: 1-2 or fruit: 1 whole piece.

·         Salad: tomatoes, cucumber & greens with lemon or vinegar dressing; 1 medium bowl.

·         Soup: grilled or broiled chicken or lentil or meat; 4 oz.

·         Cooked vegetables: 1 cup

·         Rice: wholegrain rice; 1 cup

·         Dessert: 1 small piece.

·         Water and unsweetened drinks; ample water intake is encouraged

150 – 300 Kcal (snake 2: 10 – 20%):

·         Walnuts: one handful; 6 tablespoons.

·         Water and unsweetened drinks; ample water intake is encouraged

Day15: caloric-guided meals.

Ramadan nutritional application toolkit of 1800 Kcal/day for Middle East patients:

                540 – 720 Kcal (Suhoor: 30 -40%):

·         Beans 1.5 cups

·         Yogurt: 1 tub; with low-fat milk

·         Cheese: 2 oz./ 2 slices; low salt for hypertensives

·         Small olive: 5

·         Wholegrain bread: 2 thin slices.

·         Tomato and cucumber salad plus 1 egg.

·         Water and unsweetened drinks; ample water intake is encouraged.

180 – 360 Kcal (snake 1: 10 – 20%):

·         Dates: 1-2

·         Water and unsweetened drinks; ample water intake is encouraged.

720 – 900 Kcal (Iftar: 40 50%):

·         Dates: 1-2 or fruit: 1 whole piece.

·         Salad: tomatoes, cucumber & greens with lemon or vinegar dressing or 2 teaspoonfuls of olive oil dressing; 1 medium bowl.

·         Soup: grilled or broiled chicken or lentil or meat; 4 oz.

·         Cooked vegetables: 1.5 cups

·         Rice: wholegrain rice; 1.5 cups

·         Dessert: 1 small piece.

·         Water and unsweetened drinks; ample water intake is encouraged

180 – 360 Kcal (snake 2: 10 – 20%):

·         Walnuts: one handful.

·         Milk: 1 glass; 6 tablespoons.

·         Water and unsweetened drinks; ample water intake is encouraged.

Day 16: caloric-guided meals.

Ramadan nutritional application toolkit of 2000 Kcal/day for Middle East patients:

                600 – 800 Kcal (Suhoor: 30 -40%):

·         Beans 1.5 cups

·         Yogurt: 1.5 tubs; with low-fat milk

·         Cheese: 2 oz./ 2 slices; low salt for hypertensives

·         Small olive: 10

·         Wholegrain bread: 2 thin slices.

·         Tomato and cucumber salad plus 1 egg.

·         Water and unsweetened drinks; ample water intake is encouraged.

200 – 400 Kcal (snake 1: 10 – 20%):

·         Dates: 1-2

·         Water and unsweetened drinks; ample water intake is encouraged.

800 – 1000 Kcal (Iftar: 40 50%):

·         Dates: 1-2 or fruit: 1 whole piece.

·         Salad: tomatoes, cucumber & greens with lemon or vinegar dressing or 2 teaspoonfuls of olive oil; 1 medium bowl.

·         Soup: grilled or broiled chicken or lentil or meat; 4 oz.

·         Cooked vegetables: 2 cups

·         Rice: wholegrain rice; 1.5 cups

·         Dessert: 1 small piece

·         Water and unsweetened drinks; ample water intake is encouraged

200 – 400 Kcal (snake 2: 10 – 20%):

·         Walnuts: one handful.

·         Milk: 1 glass; 6 tablespoons

·         Water and unsweetened drinks; ample water intake is encouraged

 

Day 17: caloric-guided meals.

Ramadan nutritional application toolkit of 1200 Kcal/day for Malaysia and Asian Muslims patients:

                300 – 480 Kcal (Suhoor: 30 -40%):

·         Green salads or Ulams: 1 cup.

·         Stir-fried beans with egg: 0.5 cups.

·         Wholegrain bread: 2 slices or wholegrain rice: 1 cup (2 scoops).

·         Milk: 1 glass, with oats: 3 tablespoons or unsweetened malted drink: 3 tablespoons with mild.

·         Water or unsweetened drinks.

120 – 240 Kcal (snake 1: 10 – 20%):

·         Dates: 1-2.

·         Baked chicken curry puff: 1 piece of medium size or papiah basah: 1 piece or pau ayam: 1 piece.

·         Water and unsweetened drinks; ample water intake is encouraged.

480 – 600 Kcal (Iftar: 40 50%):

·         Dates: 1-2.

·         Green salads or ulams: 1 cup.

·         Tempeh with anchovies: 1 cup.

·         Lean grilled chicken in sambal: 1 palm size.

·         Rice: wholegrain or parboiled basmati: 1 cup.

·         Water and unsweetened drinks; ample water intake is encouraged

120 – 240 Kcal (snake 2: 10 – 20%):

·         Milk: 1 glass.

·         Water and unsweetened drinks; ample water intake is encouraged.

Or

·         Wholegrain bread: 1 slice, with sardines and vegetables: 3 tablespoons

·         Water or unsweetened drinks.

 

Day 18: caloric-guided meals.

Ramadan nutritional application toolkit of 1500 Kcal/day for Malaysia and Asian Muslims patients:

        450 – 600 Kcal (Suhoor: 30 -40%):

·         Green salads or Ulams: 1 cup.

·         Stir-fried beans with egg: 0.5 cups.

·         Baked fish in sambal: 0.5 palm size.

·         Wholegrain bread: 2 slices or wholegrain rice: 1 cup (2 scoops).

·         Milk: 1 glass, with oats: 3 tablespoons or unsweetened malted drink: 3 tablespoons with mild.

·         Water or unsweetened drinks.

150 – 300 Kcal (snake 1: 10 – 20%):

·         Dates: 1-2.

·         Baked chicken curry puff: 1 piece of medium size or papiah basah: 1 piece or chicken dumpling: 1 piece.

·         Water and unsweetened drinks; ample water intake is encouraged.

600 – 750 Kcal (Iftar: 40 50%):

·         Dates: 1-2 or fruit: 1 whole piece.

·         Green salads or ulams: 1 cup.

·         Tempeh with anchovies: 1 cup.

·         Lean grilled chicken in sambal: 1 palm size.

·         Low-fat soup with lean meat (1 matchbox) and vegetables: 1 small bowl.

·         Rice: wholegrain or parboiled basmati: 1 cup.

·         Water and unsweetened drinks; ample water intake is encouraged

150 – 300 Kcal (snake 2: 10 – 20%):

·         Milk: 1 glass with oats: 3 tablespoons.

·         Water and unsweetened drinks; ample water intake is encouraged.

Or

·         Wholegrain bread: 2 slices, with sardines and vegetables: 3 tablespoons

·         Water or unsweetened drinks.

Day 19: caloric-guided meals.

Ramadan nutritional application toolkit of 1800 Kcal/day for Malaysia and Asian Muslims patients:

        540 – 720 Kcal (Suhoor: 30 -40%):

·         Green salads or Ulams: 1 cup.

·         Stir-fried beans with egg: 1 cup.

·         Baked fish in sambal: 1 palm size.

·         Wholegrain bread: 2 slices or wholegrain rice: 1 cup (2 scoops).

·         Milk: 1 glass, with oats: 3 tablespoons or unsweetened malted drink: 3 tablespoons with mild.

·         Water or unsweetened drinks.

180 – 360 Kcal (snake 1: 10 – 20%):

·         Dates: 1-2.

·         Baked chicken curry puff: 1 piece of medium size or papiah basah: 1 piece or chicken dumpling: 1 piece.

·         Water and unsweetened drinks; ample water intake is encouraged.

720 – 900 Kcal (Iftar: 40 50%):

·         Dates: 1-2 or fruit: 1 whole piece.

·         Green salads or ulams: 1 cup of olive oil: 1 teaspoonful.

·         Tempeh with anchovies: 1 cup.

·         Lean grilled chicken in sambal: 1 palm size.

·         Low-fat soup with lean meat (3 matchboxes) and vegetables: 1.5 small bowls.

·         Rice: wholegrain or parboiled basmati: 1.5 cups.

·         Water and unsweetened drinks; ample water intake is encouraged

180 – 360 Kcal (snake 2: 10 – 20%):

·         Milk: 1 glass with oats: 3 tablespoons.

·         Water and unsweetened drinks; ample water intake is encouraged.

Or

·         Noodle soup with meat: 1 small bowl with green vegetables.

·         Water or unsweetened drinks.

Day 20: caloric-guided meals.

Ramadan nutritional application toolkit of 2000 Kcal/day for Malaysia and Asian Muslims patients:

        600 – 800 Kcal (Suhoor: 30 -40%):

·         Dates: 1 -2

·         Green salads or Ulams: 1 cup.

·         Stir-fried beans with egg: 1 cup.

·         Baked fish in sambal: 1 palm size.

·         Wholegrain bread: 2 slices or wholegrain rice: 1 cup (2 scoops).

·         Milk: 1 glass, with oats: 3 tablespoons or unsweetened malted drink: 3 tablespoons with mild.

·         Water or unsweetened drinks.

200 – 400 Kcal (snake 1: 10 – 20%):

·         Dates: 1-2.

·         Baked chicken curry puff: 2 piece of medium size or papiah basah: 1 piece or chicken dumpling: 1.5 pieces or chicken dumpling: 1.5 pieces.

·         Water and unsweetened drinks; ample water intake is encouraged.

800 – 1000 Kcal (Iftar: 40 50%):

·         Dates: 1-2 or fruit: 1 whole piece.

·         Green salads or ulams: 1 cup of olive oil: 1 teaspoonful.

·         Tempeh with anchovies: 1 cup.

·         Lean grilled chicken in sambal: 1 palm size.

·         Low-fat soup with lean meat (4 matchboxes) and vegetables: 2 small bowls.

·         Rice: wholegrain or parboiled basmati: 1.5 cups.

·         Water and unsweetened drinks; ample water intake is encouraged

200 – 400 Kcal (snake 2: 10 – 20%):

·         Milk: 1 glass with oats: 3 tablespoons.

·         Water and unsweetened drinks; ample water intake is encouraged.

Or

·         Noodle soup with meat: 1 small bowl with green vegetables.

·         Water or unsweetened drinks.

Day 21: insulin pumps are a considerable option for patients on insulin therapy and intended to fast during the Holy Month. Unlike the conventional insulin injection regimen, the insulin pumps can abort, reduce, prevent and treat the hypoglycemic episodes that may occur during fast. Monitoring the blood glucose level allow a minute to the minute evaluation of the blood glucose level and dose adjustment accordingly. The pump may stop release insulin when the blood glucose level reaches unwelcomed level thus, guarding against hypoglycemia. The conventional subcutaneous insulin injection continues to release insulin irrespective of the blood glucose level. self-monitoring of the blood glucose level is highly advised to detect such condition. Oral glucose intake is the only way to combat the hypoglycemic episode.

It is important to take care of pump failure and tissue failure. Either of these conditions can cause hypoglycemia without being noticed. Once more, it is emphasized that home blood glucose monitoring is very important for insulin-treated patients.

Day 22: the newly discovered antidiabetic agents including α-glucosidase inhibitors, incretin-based therapy, and glitazones need 2-4 weeks before attaining the full anti-diabetic effect. Therefore, the diabetic patients who are intended to shift to one of the new anti-diabetic agents should start medications and the associated diet regiment at least 4 weeks before Ramadan. Some medications cannot be easily tolerated due to side effects. The tolerance of the agents should be considered as well.

Drug combination should also be considered when more than one anti-diabetic agent is going to be used for glycemic control. Most of the newly administered agents may cause hypoglycemia in combination with insulin and sulfonylureas. Dose titration and wise adjustment should be carried out few months before the Holy Month. Glitazones should not be given to patients with cardiac problems because of the speculation of cardiac affection of these agents. Drug selection and shit should be under strict medical observation. Monitoring of blood glucose level should be skilled before the Holy Month.

Day 23: prevent a hypoglycemic attack:

      Diet modification should be counterbalanced by anti-diabetic medication. Do not omit or delay your meals. Snakes should be within the medication range.

      When the physical activity changes, the diet, and medication should be changed accordingly. According to your insulin sensitivity, the insulin dose should be reduced by one third when the duration of exercise increases significantly.

       Learn, from your health caregiver, the onset, peak, and duration of the type of insulin you inject. Learn the effect of decreasing or increasing the dose.

      Self-monitor your blood glucose daily preprandial (before a meal) and postprandial (after a meal); occasionally at bedtime and midday.

      Record your glycemic pattern. It will show the hypoglycemic and hyperglycemic episodes. The health caregiver will benefit from the record in guiding your treatment.

      Carry diabetes medical identification necklace, bracelet or wallet card. The medical identifications will guide the responders how to help you in case of emergency.

Day 24: what to do when you are sick in Ramadan and manage to keep fast.

      Never stop your anti-diabetic medication. You may need to modify the dose and the frequency. Think of breaking the fast. Consult your physician before doing any changes.

      Focus on self-monitoring your blood glucose level. Do it more frequently than before.

      Test your urine ketones by urine strips. If high, terminate fast and consult your health team.

      Continue eating the usual amount of carbs and calories divided into smaller meals than before getting sick. Pick up the easy-on-the-stomach food.

      You can have liquid carbs if necessary. 50 gm of carbs every 3-4hs will be just fine.

      Maintain on non-caloric, non-caffeinated fluids. Drink ample amount of water to keep hydrated most of the time.

Contact your healthcare team.

      Discuss having sugar foods such as soft drinks and gelatin with your health care provider.

Day 25: Exercise: it improves glycemic control for type 2 diabetes. For type 1 diabetes, exercise improves fitness; no effect on glycemic control. Blood glucose level response to exercise in Ramadan depends on the following items:

      The intensity of exercise.

      Timing and type of the pre-exercise meal.

      Timing and type of insulin injection or oral agents.

      Blood glucose level prior to practice.

      The fitness of the individual.

Exercise for type 1 diabetes:

      Planned exercise: insulin dose modification prior to exercise.

      Non-planned exercise: a carb supply should be taken before exercise. Check the blood glucose frequently.

      Postpone exercise if the blood glucose level is below 3.3 mmol/l.

      Additional 15g of carbs can be given every 30-60 min above the normal routine.

      Check the blood glucose every 30 min for a moderate exercise routine.

      Schedule exercise to follow meals and when the blood glucose is high. Both insulin and diet adjustment is needed to avoid hypoglycemia during practicing your routine.

Day 26 what you eat: Mediterranean regimen:

physical activity and enjoyment: payer is included in the exercise program.
DAILY SERVING	fruits, vegetables, wholegrain bread, wholegrain pasta, rice, grains, potatoes, olive oil, beans, nuts, legumes, seeds, herbs.	Minimally use processed foods. Olive oil replaces butter and margarine. wholegrain bread & pasta are superior to refined grain bread and pasta. Total fat: 25%- 35% of total energy. Saturated fat: 7% of total energy.
TWO TIMES PER DAY	fish and seafood	fish and seafood are devoid of bad cholesterol.
DAILY TO WEEKLY	poultry, eggs, cheese, yogurt	Low-to-moderate amounts of cheese and yogurt. 7 eggs per week.
LESS OFTEN	sweets and meats.	Fresh fruit as daily dessert. Red meat: 12 oz. To 16 oz. Per month

Day 27: I:C ratio

The insulin to carbs ratio is used to estimate the amount of regular insulin you need before your meal. It can be calculated by dividing the number of grams of carbs consumed at any meal by the prandial insulin units. When you consume, for example, 75 gm of carbs at breakfast and you take only 5 units of prandial insulin to control your glycemic profile, the I:C ratio is 75/5 = 15. The average of I:C ratio can be 1 unite of insulin for 10-15 gm of carbs for adults. The correction factor may be used to adjust the pre-prandial high or low blood glucose level. A factor of 1800 is used for rapid-acting insulin. A factor of 1500 is used for regular insulin. Example: if a patient uses 60 units of total daily insulin and rapid insulin before a meal, the correction factor would be 1800/60 = 30. If the pre-prandial blood glucose is 169mg/dl and the target is 130 mg/dl, the correction is 1 extra unit to nearly adjust the blood glucose to the target (169-130=39).

Day 28: carbs count:

Each carbohydrate serving equals to 15gms of carbs approximately. Average weight individual needs about 3-4 servings (45-60gms) of carbs each meal. This figure is subject to increase according to caloric needs. Pregnant diabetics, nursing ladies, and ill patients would need more caloric intake than usual. Medication and activity affect the caloric needs as well. Motivated patients learn the carbs count for proper adjustment and modification of the short-acting insulin before the meal. The disadvantage of carbs count is weight gain. Unhealthy eating, hypoglycemia, and high lipid profile are associated with the carbs count.

Day 29: glycemic index:

The glycemic index is a scale used to categorize carbs-rich food according to the rise of blood glucose level. The glycemic index is used to determine which carbs are useful and which are not. For diabetic Muslims in Ramadan, the carbs of high fiber content and low glycemic index are of great benefit. The latter type of carbs is characterized by delaying absorption of glucose into the bloodstream. Therefore, no glucose spikes follow the consumption of these types of carbs. Generally, non-starchy fruits and vegetable have a low glycemic index; legumes and whole grains have a moderate glycemic index; refined grain food and potatoes have a high glycemic index. Glycemic index is advised by the American diabetic association. However, the method of cooking and the additives change the glycemic index of the carbs meal. for better practice, you should learn how a certain type of food affects your blood glucose rather than adhering to the glycemic index alone.

Day 30: self-management of hypoglycemia (low blood glucose) at home:

You should learn the symptoms of hypoglycemia and the prompt management at home or work. The symptoms include anxiety, irritability, sweating, headache, and blurring of vision. Severe cases suffer altered the conscious level and convulsion that could be life-threatening conditions. The unconscious patients need prompt help from the first responder to rescue the patient life. Diabetic ID card would show the first responder what to do.

When you have symptoms of hypoglycemia or your self-monitoring revealed blood glucose below 4.0 mmol/l, you should take 15gm of simple sugar within 15 min (15/15 rule). When the blood glucose is below 3.3 mmol/l, you should have one of the following (quick fix) foods:

3-4 glucose tablets.

½ cup (4 oz.) fruit juice.

½ cup (4 oz.) regular soft drink.

8-10 pieces of hard candy.

2 tablespoonful raisins.

1 cup non-fat milk.

 

 

 Alerta/ notificatioNs AFTER RAMADAN

TO BE SENT 1 DAY AFTER RAMADAN because of its content

The diabetic Muslim should be aware of the risks of overindulgence after Ramadan in Eid ul-Fitr. The three days following Ramadan are festival. Consume fatty creamy and sweetie food slowly and wisely. It is better to have vegetable juices, green smoothies and raw vegetables and fruits. Such healthy food supplies your body with the essential nutrients.

TO BE SENT 1 WEEK AFTER RAMADAN because of its content

The diabetic Muslim should consult his/ her health care provider for dose adjustment and medication. Assessment of the fasting month is important to understand how far you were able to take care of your diabetes in Ramadan. The assessment outcome will help you and your healthcare provider decide to fast or not the 6 days of Shawal and the following voluntary fasting days. The diabetic Muslim should understand that diabetes is a progressive disease. Therefore, he/ she should do the same regimen each year to clear the 30-days fasting safely with no complications. (150 words)

 

 

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[ii] Salti I, Benard E, Detournay B, et al. A population-based study of diabetes and its characteristics during the fasting month of Ramadan in 13 countries: results of the epidemiology of diabetes and Ramadan 1422/2001 (EPIDIAR) study. Diabetes Care 2004; 27:2306-11.

 

[iii] Miller T, Ed. Mapping the Global Muslim Population: A Report on the Size and Distribution of the World’s Muslim Population, [Internet] c2009. Washington, DC, Pew Research Center. Available from http://pewforum.org/newassets/images/reports/Muslimpopulation/Muslimpopulation.pdf. Accessed 8 October 2009.

 

[iv] Babineaux SM, Toaima D, Boye KS, et al. Multi-country retrospective observational study of the management and outcomes of patients with Type 2 diabetes during Ramadan in 2010 (CREED). Diabet Med 2015; 32:819-28.

 

[v] Chentli, F., Azzoug, S., Amani, M. E. A., & Elgradechi, A. (2013). Diabetes mellitus and Ramadan in Algeria. Indian Journal of Endocrinology and Metabolism, 17(Suppl1), S295–S298. http://doi.org/10.4103/2230-8210.119622.

 

[vi] Oulhadj F. L’avis de la diététicienne. Gérer son alimentation pendant le ramadan. [Last accessed on 2013 Jun 10]. Available from: http://www.afd.asso.fr .

 

[vii] Mission Economique-UBIFRANCE en Algérie; La filière agroalimentaire en Algérie octobre 2009 © MINEIE – DGTPE-UBIFRANCE. [Last accessed on 2013 Jun 10]. Available from:http://www.financesmediterranee.com

 

[viii] http://www.mcb.org.uk/wp-content/uploads/2014/06/Ramadan-and-diabetes-A-guide-for-patients-2013.pdf

 

[ix] Mohsin F, Azad K, Zabeen B, et al. Should Type 1 diabetics fast in Ramadan. J Pak Med Assoc 2015;65: S26-9.

 

[x] Zabeen B, Tayyeb S, Benarjee B, et al. Fasting during Ramadan in adolescents with diabetes. Indian J Endocrinol Metab 2014; 18:44-7.

 

[xi] Upala S, Sanguankeo A, Congrete S, et al. Sleep duration and insulin resistance in individuals without diabetes mellitus: A systematic review and meta-analysis. Diabetes Res Clin Pract 2015;109: e11-2.

 

[xii] Bahijri S, Borai A, Ajabnoor G, et al. Relative metabolic stability, but disrupted circadian cortisol secretion during the fasting month of Ramadan. PLoS One 2013;8: e60917.

 

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