Fielding the Dangers of Fasting and Feasting With Diabetes

'Could I Have Averted This Disaster?'

I was a young resident in August 2009 when I saw Mr Khan (name changed to protect patient privacy) in the primary care continuity clinic. He was a 52-year-old man with type 2 diabetes. In the past year that I had known him, he had turned a new leaf, making every effort to follow dietary and physical activity recommendations, and he was always adherent to his medications. In essence, he was a "model patient."

Akshay B. Jain, MD

His A1c at that time was 6.8% on metformin and glyburide, with excellent home glucose readings on self-monitoring. I congratulated him on his glycemic control, made no changes to his meds, and booked an appointment to follow up after 3 months.

About 15 days later, I was rotating in the emergency department when EMS brought in a patient with severe hypoglycemia who was found unconscious. Quickly scanning the EMS note, I noticed that the patient was on glyburide. "The PCP should have known better than to use a sulfonylurea in a patient at risk for such severe hypos," I said to my attending. Imagine my consternation when I walked into the room and saw my patient, Mr Khan, lying in the bed being revived.

I later found out that Mr Khan had been fasting for Ramadan, as he did every year. That fateful afternoon, he had been fasting for about 11 hours when he started noticing symptoms of hypoglycemia. His blood sugar was 65 mg/dL, which he knew was low, but it was still another 3 hours before he could break his religious fast, at sunset.

Helpless, he lay in bed while his worried family monitored his blood sugar every 15 minutes, watching in horror as it started dipping into the 40s and he became increasingly incoherent.

They called my clinic, where the nurse–diabetes educator appropriately informed them to give Mr Khan 15 g of carbohydrate and repeat if blood sugars remained low. However, even in his state of incoherence, Mr Khan refused to take any food or beverage orally, and the family wasn't sure if they could give him oral glucose and dishonor his fast. The last straw was when he lost consciousness, and they frantically called 911.

Standing there in the emergency department, watching Mr Khan, I couldn't help but feel responsible in a way for what had happened. Was there anything I could have done to avert this disaster?

Fasting and feasting can present conundrums for the healthcare professional (HCP) caring for patients with diabetes. Often, the HCP may not know much about the intricacies of the specific fast that the patient plans on following and may therefore be hesitant to counsel the patient.

Patients, in turn, may fear that their HCP is not knowledgeable about their fasting and will hesitate to ask for advice, relying instead on information from friends, family, and the Internet. Worse, some may stop taking diabetes medications altogether during the time of fasting.

What Is Ramadan?

Ramadan is the ninth month of the Islamic year during which Muslims worldwide observe a strict fast between sunrise and sunset. Because the Islamic calendar is lunar, each Ramadan starts about 10 days earlier than the previous year. This means that sometimes it falls in winter months when the days—and fasts—are short. In the summer months, when there are more daylight hours, the fasts are long. This year, Ramadan will start on May 5 and continue until June 4.

Those exempt from fasting include children younger than 12 years; people who are ill; travelers; and menstruating, pregnant, or nursing women.

Healthy Muslims are obliged to abstain from all food, drink, and oral medications from dawn to sunset throughout the month. Most people eat two major meals a day—suhoor (meal before dawn) and iftar (meal after sunset). Many people also have snacks well into the night, which are often foods that are high in fat and have a high glycemic index.

There can be significant glycemic variability of blood sugars during Ramadan, with studies showing up to a 7.5-fold rise in hyperglycemia and 5-fold rise in hypoglycemia in patients with type 2 diabetes.^[1,2]

Another important consideration is that certain Muslims may also follow an up to 3-day-long Sugar Feast (Şeker Bayramı or Eid al-Fitr) at the end of the holy month, which marks the end of Ramadan. This is a celebratory period where gifts are exchanged and there is increased consumption of high-carb celebratory treats. Many Muslims will indulge in communal feasting, with family and friends eating together from a single large platter. This may cause one to lose judgement of individual portion sizes, leading to glycemic surges.

I strongly encourage patients to practice portion control, ensure hydration, restart their pre-Ramadan diabetes medication regimen, and monitor blood sugars closely during the time of the Sugar Feast.

It is important to note that Muslims who did not fast may also participate in the Sugar Feast. Therefore, the above recommendations need to be discussed even with those who say that they do not plan to fast during Ramadan.

Islamic scholars advise Muslims to ask their HCPs about their ability to fast safely during Ramadan; therefore, it is very important that all HCPs have a working knowledge of Ramadan-specific counseling of patients with diabetes.

How Do You Know Who Will Be Fasting?

Ask whether your patient plans on fasting during Ramadan. Being a non-Muslim myself, I have seen that many patients do not volunteer this information because they might feel that I wouldn't understand their practices.

If they answer in the affirmative, it is okay to ask how many days they intend to fast. Often, this will lead them to ask me if I feel that it is safe for them to do so. Asking patients specifically about their plans during Ramadan helps to create an environment where they feel that all stakeholders are invested in ensuring healthy fasting.

Data from the CREED study^[3] indicate that about 95% of Muslims with type 2 diabetes fast for at least 15 days during Ramadan. However, only about 64% fast for all days of the month, while 31% fast for less than 30 days. Hence, there is significant risk for intraday and interday glycemic variability on the basis of whether the patient is fasting or not and what medication adjustments have been made.

Is Your Patient Too Sick to Fast?

The Koran specifically exempts the sick from the duty of fasting, especially if fasting might lead to harmful consequences for the individual. Patients with diabetes can fall under this category, and it is strongly recommended that physicians do a risk preassessment for the patient at least 3-4 weeks before the start of Ramadan.

Very high-risk patients include those with poorly controlled type 1 diabetes, advanced renal disease, cognitive dysfunction, or recent history of hypo/hyperglycemic emergencies.
High-risk patients include those with poorly controlled type 2 diabetes or who are on multiple daily injections of insulin.
Moderate/low-risk patients are those with well-controlled type 2 diabetes who are on oral agents and/or basal insulin therapy.

HCPs are recommended to advise that very high-risk patients must not fast, high-risk patients should not fast, and moderate/low-risk patients can fast with medical advice.^[4,5]

Some Tips for Safely Observing Ramadan

To fast or not to fast is ultimately the patient's decision, and HCPs are encouraged to respect the patient's wishes while counseling on safe practices.
Develop an individualized plan for each patient before the start of Ramadan wherein the dose of hypoglycemia-inducing medications can be adjusted appropriately according to the current guidelines.^[4]
Patients should be advised to check their blood sugars two to six times a day (including during the daytime, when they are not eating), depending on their risk for hypo- or hyperglycemia. Consider the use of flash or continuous glucose monitoring during the month of fasting in high-risk patients or those with significant glycemic variability.
Patients should be clearly counseled to break the fast if their blood sugar goes below 70 mg/dL (3.9 mmol/L) or above 300 mg/dL (16.6 mmol/L); if they develop nausea, vomiting, or orthostatic dizziness; or if they notice elevated ketone levels on testing or suddenly fall ill. Consider giving high-risk patients a prescription for a glucagon emergency kit and educate family members.
For patients who prefer not to take any insulin before breaking the fast, consider the use of ultra-short-acting mealtime insulins (eg, Fiasp), which can be taken with the first bite or within 20 minutes of initiating a meal.
SGLT2 inhibitors: Caution patients about dehydration and signs of diabetic ketoacidosis. For those with polyuria, take at the night meal (iftar) or consider discontinuing temporarily.
GLP-1 receptor agonists: Avoid initiating or increasing the dose within 4 weeks of onset of fasting because of the increased risk for gastrointestinal side effects.
Aim for relaxed glycemic targets (5.5-7.5 mmol/L or 100-135 mg/dL for fasting/premeal) in patients at risk for hypoglycemia.
There is an increased risk of stacking insulin when the duration of daytime hours is >15.
Advise patients to consume simple carbs at the evening meal and complex carbs during the morning meal. Low-glycemic-index, high-fiber carbohydrates are preferable. Low-calorie snacks such as nuts, fruits, or vegetables can be consumed between meals at night.
Watch for hyperglycemia during the 1- to 3-day Sugar Feast at the end of Ramadan.
A post-Ramadan medical assessment to discuss glycemic excursions and to formulate a plan for future fasting would be ideal.

With proper medical guidance, it can be possible to achieve safe fasting practices for the appropriate patient during Ramadan.

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