Published on 21 March 2023

Fasting with diabetes - hear from an expert

The concept of fasting is practised by millions of people worldwide, and is a feature in several religious calendars, including Islam (Ramadan), Judaism (Yom Kippur) and Christianity (Lent). Forgoing all or some types of nourishment for a certain period of time, is often taken as an opportunity to empathise with others’ suffering and focus one’s energy on faith and prayer. 

But fasting may not be safe for many people with diabetes – and for those who choose to fast, it comes with a considerable amount of preparation and self-monitoring. If not managed carefully - or when practised against medical advice - fasting could lead to a risky imbalance in blood glucose levels. 

First and foremost, anyone with diabetes should consult a doctor before deciding whether to fast. Some people may be able to fast safely, but others will be advised not to.  

Ahead of the month of Ramadan, we spoke to Dr Eman Sheshah, Consultant Endocrinologist at Kingdom Hospital & Consulting Clinics, Riyadh (Saudi Arabia), to learn more about diabetes management and fasting. In Islam, Ramadan is a month of fasting where no food or drink can pass one’s lips between dawn and sunset – expected to land this year between 22 March and 21 April. In this interview, Dr Sheshah outlines key medical advice, provides tips for monitoring diabetes during Ramadan and offers suggestions for a meal routine. 

What advice would you give someone fasting with diabetes?
People with diabetes intending to fast during Ramadan are categorised into low, moderate and high-risk groups. Pre-Ramadan evaluation and assessment is critical, alongside education to ensure safe fasting during Ramadan. Different medications to treat diabetes have varying levels of hypoglycaemic risk, and Ramadan-specific treatment regimens, including dose and/or timing adjustments, should be produced for each individual with diabetes.

How should people with diabetes prepare for the month of Ramadan and what adjustments need to be made in the diabetes therapy?
With the correct advice and support from healthcare professionals, most people with type 2 diabetes can fast safely during Ramadan. A pre-Ramadan assessment is vital for any individual with type 2 diabetes that intends to fast in order to evaluate the risks, to educate the person in self-management of the condition during Ramadan and to produce a personalised treatment plan. 

Please note, the DAR International Alliance guidelines advise that fasting in adolescents and adults with type 1 diabetes carries a high risk. 

What are the main challenges of fasting with diabetes?
Because of the metabolic nature of the condition, people living with diabetes are at greater risk of complications from marked changes in food and fluid intake. Potential health hazards include hypoglycaemia, hyperglycaemia, dehydration and acute metabolic complications such as diabetic ketoacidosis (DKA).

Are there advantages you can highlight for people with diabetes to participate in Ramadan?
Fasting during Ramadan may provide enduring benefits. Indeed, Ramadan can provide an opportunity for a better lifestyle, assisting weight loss and smoking cessation (as smoking is also prohibited from dawn until dusk). For people with diabetes who choose to fast, Ramadan may help to strengthen communication with their physician - and can provide an opportunity to improve diabetes management, with a focus on self-care and the regulation of medication and meal timing.

How often should the blood glucose level be checked during Ramadan?
Self-monitoring of blood glucose (SMBG) is an essential component of diabetes care. During Ramadan, individuals should be provided with the tools and knowledge to carry out self-monitoring of blood glucose. 

The frequency of monitoring depends on many factors including the type of diabetes and current medications, but should be carried out regularly by all. For those at moderate or low risk, this may be once or twice a day. Those at high or very high risk should check their blood glucose levels several times a day.

A regular routine might look like this:

  1. Pre-dawn meal (suhoor)
  2. Morning
  3. Midday
  4. Mid-afternoon
  5. Pre-sunset meal (iftar)
  6. 2 hours after iftar
  7. At any time when there are symptom of hypoglycaemia / hyperglycaemia or feelings of being unwell

Can people with diabetes still go about their usual routine while fasting?
Yes. Adequate nutrition and meal intake, adjustments in medication dosages, and healthy lifestyle behaviours can guide individuals to fast in a safe and healthy manner. 

How about exercising while fasting, is it advisable or maybe even recommended?
People with diabetes are encouraged to do regular light to moderate activity while fasting. During Ramadan, tarawih prayers (and other structured time prayers) are recognised as part of daily exercise. Rigorous exercise is not recommended. 

In which situations do you recommend breaking the fast?
Individuals should be educated to recognise the symptoms of hypoglycaemia and hyperglycaemia and be advised to test their blood glucose regularly whenever any of these complications (or an acute illness) occur. They must also be prepared to break the fast if necessary. 

Do you have go-to meal or snack recommendations for iftar (the meal to break the fast after sunset) and suhoor (the meal taken just before sunrise)?
Here are some key top tips for nutrition during Ramadan: 

  • Divide daily calories between suhoor and iftar, with 1-2 snacks if necessary
  • Ensure meals are well balanced
  • Include low glycaemic index, high-fibre foods, such as beans, whole grains, fruits and vegetables
  • Minimise foods high in saturated fats, such as ghee, fatty meats
  • Avoid sugary desserts
  • Use small amounts of oil when cooking, and use alternatives such as mono- or polyunsaturated oils: e.g., olive, rapeseed
  • Keep hydrated between sunset and sunrise by drinking water and other non-sweetened beverages
  • Avoid caffeinated and sweetened drinks

Is there a specific guidance for women with diabetes who are pregnant or on their period during Ramadan?
Islamic regulations provide all pregnant women with the option to not fast if they feel worried about their own health, foetal wellbeing or if they feel burdened with fasting during pregnancy. Many pregnant women with pre-existing diabetes or gestational diabetes mellitus (GDM) are considered a high-risk group for fasting during Ramadan.

Pregnant women with pre-existing diabetes who intend to fast during Ramadan should be identified by a healthcare professional several months prior to Ramadan. A complete assessment should be conducted, and a proper fasting risk evaluation should be performed. Patient education prior to Ramadan is essential to ensure maternal and foetal safety, regardless of their fasting decision.

Is there any specific guidance for other high-risk groups, including children with type 1 diabetes or seniors living with diabetes?
These high-risk group should avoid fasting: If people with diabetes insist on fasting then they should:

  • Receive structured education
  • Be followed by a qualified diabetes team
  • Check their blood glucose regularly (SMBG)
  • Adjust medication dose as per recommendations
  • Be prepared to break the fast in case of hypo- or hyperglycaemia or worsening of other related medical conditions

More information on fasting with diabetes is available in the DAR International Alliance guidelines

The Roche Diabetes Care website does not provide medical or legal advice. Roche Diabetes Care blog articles are not scientific articles, but intended for informational purposes only.

Medical or nutritional information on the Roche Diabetes Care website is not intended to replace professional medical advice, diagnosis or treatment. Always consult a physician or health care provider with any questions you may have regarding a medical condition