Fasting with Diabetes

Everyone is different, so Diabetes Canada recommends seeing your health care provider 1-3 months before ramadan to determine if it is safe for you to fast [1].

Diabetes is a widespread issue in the Muslim community – you may even know someone living with it! There are over 148 million Muslims living with diabetes around the world [2]. Checking your blood sugar, taking insulin, and remembering to take your medications… how do these coexist with fasting during the beautiful month of Ramadan? What does Islam say about this, and what does today’s research recommend?

ISLAM AND FASTING

Fasting in Islam is a requirement for healthy adults, however Allah (God) has allowed (and even recommended) that people with serious illnesses not fast.

This is clearly in the Qur’an (Islam’s Holy Book), which includes the following verse:

The month of Ramadan [is that] in which was revealed the Qur’an, a guidance for the people and clear proofs of guidance and criterion. So whoever sights [the new moon of] the month, let him fast it; and whoever is ill or on a journey – then an equal number of other days. Allah intends for you ease and does not intend for you hardship and [wants] for you to complete the period and to glorify Allah for that [to] which He has guided you; and perhaps you will be grateful.” (Surah al-Baqarah, Ayah 185) [3]

Islamic scholars have explained that a person living with any sickness/medical condition that would worsen with fasting should avoid it [4]. In addition, there are accounts of the Prophet Muhammed (pbuh) stating that, “Verily, Allah loves for you to take His concessions, just as He dislikes you to be disobedient” [5]. These proofs, among others, show that Muslims should not feel bad for avoiding the fast for health reasons. But how does this tie into diabetes?

DIABETES

Fasting while living with diabetes can result in some serious risks [6]:

  • Hypoglycemia, which means low blood sugar levels (<3.9mmol/L)
  • Hyperglycemia, which means high blood sugar levels (>16.7mmol/L) [7]
  • Dehydration & thrombosis, especially in hot and long days of fasting
  • Diabetic ketoacidosis, which means your body is breaking down fat, making your blood acidic. This is very dangerous and can lead to hospitalization.

Diabetes Canada explains that those with low to moderate risk that can fast with medical advice usually have diabetes that’s well controlled, healthy lifestyle measures in place, or an otherwise healthy individual that is treating diabetes with medication such as metformin, acarbose, incretin-therapies (DPP-4 inhibitors or GLP-1 RA), second generation SU, SGLT2 inhibitors, TZD) or basal insulin [8].

If you would like more information on risks relating to fasting in Ramadan for those living with diabetes speak to your family doctor and visit Diabetes Canada’s Ramadan and Diabetes Guidelines.

Always remember to check your blood sugars more often in Ramadan to make sure they are not too low or too high. Keep an eye on your symptoms for each and ask your doctor how to treat a high or low!

If you and your doctor decide that fasting in Ramadan is safe for you, one of the ways to help stabilize your blood sugars is to be mindful of what and when you eat! This is where evidenced based advice from a Dietitian comes in handy!

NUTRITION

Suhoor (The Pre-Dawn Meal):

Suhoor is important and should be eaten as close as possible to the fajr (dawn prayer). An early suhoor means you’re just making the fast even longer – and we don’t want that!

To support this practice, we know the “Prophet (pbuh) said: “My Ummah (nation of followers) will not cease being upon goodness as long as they hasten in breaking the fast and delay the suhoor.” (Authentic, Musnad Imam Ahmad) [9]

Tips for Suhoor:

  • Have suhoor! This will help break up your daily food intake so you’re not just having one big meal at iftaar (the breaking of the fast) aka a sugar spike!
  • Eat a good amount! This will increase energy levels and lower the chance of low blood sugars

Be sure to include:

  • Carbohydrates: Have whole grains and foods with low glycemic index (these will raise blood sugars slowly)
    • Examples: whole grain bread/pita, whole wheat chappatti, laxoox/enjeero made with whole wheat flour, sareen (barley porridge), daal (lentils), or ful (fava beans).
  • Protein: Have protein to help you feel full longer.
    • Choose meat options, such as lean poultry, beef, or fatty fish, or meat alternatives, like eggs, beans, lentils, and tofu.
  • Fat: Have healthy unsaturated fats to help you feel full.
    • Choose nuts, seeds, avocado, fatty fish, and unsaturated vegetable oils (olive, canola, flaxseed, sunflower, etc).

An example Suhoor: Vegetable omelet with whole grain bread, a cup of berries and water

Iftar:

As tempting as it is, try not to overeat! This will spike your blood sugars! Have a date and water to rehydrate, and avoid the fried samosa/sambusa/pakora/bhajia etc! They have little nutrition, and can fill you up when your body needs a nutritious and fulfilling meal. Ramadan is a time for spiritual cleansing, and it can be a great time to clean your diet too as your body is an amana!

Tips for Iftaar:

  • Follow the Plate Method:
    • ½ plate with your favourite vegetables
    • ¼ plate with protein
    • ¼ plate with carbohydrates
  • As with suhoor, choose whole grains and low glycemic index foods (to avoid raising blood sugars too high), lean meats or meat alternatives, and healthy unsaturated fats.

An example of an iftar meal: Dolma (meat stuffed grape leaves) with whole wheat couscous, & fattoush salad.

Ramadan is a time for spiritual cleansing, and it can be a great time to clean your diet too as your body is an Amana!

Snacks:

Incorporate two snacks between iftar and suhoor.

  • Timing is everything. Going for taraweeh (Ramadan night prayers) at 10pm? Consider having a snack on your way to the mosque/musalla. Rehydrate with water in between prayers and go in for a second snack on your way back home before bed. (Remember: if you avoid overeating at iftar, you leave room for snacks to space out your food intake- i.e stable blood sugars)
  • These snacks should ultimately include both protein and carbs, so that the protein can slow down the absorption of carbs and not cause your blood sugars to spike.
  • Great ideas for snacks include greek yogurt (a good source of protein!) with some tropical fruit, such as mango. Maybe even get really fancy and have some almond butter (oh là là!) on whole grain crackers. Have fun with it!

Let us know what snack and meal ideas you come up with this Ramadan in the comments. We’d love to hear from you!

**Ask your family doctor if fasting in Ramadan is safe for you. If you do decide to fast, it is important to talk to your doctor about any adjustments required, such as: medication dosage and timing, how often you should check your blood sugars, as well as when and how you should break your fast. **

*Please be aware that these are general guidelines. Nutrition and intake varies by age, sex, height, activity, being pregnant or breastfeeding, and medical conditions. For more information or to sit with one of our dietitians for an individualised nutrition counselling session, please contact us at amananutrition@gmail.com or visit our Contact Us page to book your first online appointment.

Until next time,

Huda Amareh, MAHN, RD & Almas-Sadaf Shaikh, PMDip, RD

Amana Nutrition


References:

[1] Diabetes Canada, (2018). Ramadan and Diabetes. Retrieved from http://guidelines.diabetes.ca/healthcareprovidertools/ramadan-and-diabetes

[2] 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.

[3] Surah al-Baqarah, Ayah 185. Sahih International English Translation.

[4] Al-Mawsoo’ah al-Fiqhiyyah, V. 2. (2010, July 24). Reasons for which one may excused from fasting in Ramadaan – Islam Question & Answer. Retrieved from https://islamqa.info/en/answers/23296/reasons-for-which-one-may-excused-from-fasting-in-ramadaan  

[5] Musnad Aḥmad ibn Hanbal 5832. Sahih (authentic) according to Al-Albani

[6] Hassanein, M. (2018). The International Diabetes Federation- Diabetes and Ramadan: A Challenge and an Opportunity? . [PDF slides]. Retrieved from

[7]  American Diabetes Association. (2004). Hospital admission guidelines for diabetes. Diabetes Care, 27(suppl 1), s103-s103.

[8] Bajaj, H. S., Abouhassan, T., Ahsan, M. R., Arnaout, A., Hassanein, M., Houlden, R. L., … & Verma, S. (2019). Diabetes Canada Position Statement for People With Types 1 and 2 Diabetes Who Fast During Ramadan. Canadian journal of diabetes, 43(1), 3-12.

[9] Musnad Aḥmad ibn Hanbal. Sahih (authentic).

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