Malaysia has one of the highest percentages of people suffering from diabetes in the world. These people who
also fast during this month of Ramadan are among the 1.2 million Malaysian Muslims affected by diabetes.
Prof Dr Nor Azmi Kamaruddin, Head of the Endocrine Unit and Consultant Endocrinologist at the Universiti Kebangsaan Malaysia Medical Centre (UKMMC), said according to studies, those with type 1 diabetes manage to fast for an average of 23 days, whereas type 2 diabetic individuals can fast for an average of 27 days during this period.
However, he acknowledged that the majority of Malaysian Muslims were able to perform their religious duties during Ramadan, despite being diagnosed with diabetes and its complications.
Having diabetes means that a person will have to remain vigilant about their blood sugar levels or they might suffer the effects of high blood sugar, known as hyperglycemia, which could result in various health complications.
People with diabetes often experience fluctuations in their blood sugar levels which can either be high (resulting in hyperglycemia) or low (resulting in hypoglycemia).
It is the inability to produce adequate amounts of the blood sugar regulating hormone, known as insulin, which is the main cause of this disease.
Complexity of Diabetes management
Prof Dr Nor Azmi cautioned that the complexity of diabetes management becomes more apparent in Muslims during the fasting period because of dietary changes in the time of consumption and abstaining from of their daily food intake that can cause problems with maintenance of the body’s ability to regulate blood sugar levels.
In a write-up focusing on diabetes management during Ramadan, he explained that on a normal day, people with diabetes would take their insulin shots or oral anti-diabetes pills in the morning, afternoon and night after each meal, but this treatment cycle is hindered by a 14-hour fasting period.
Those who fast can take only two insulin shots each day, one during the Sahur period and the other after the breaking of fast in the evening.
The long interval between meals instantly increases the risk of hypoglycemia, and overindulgence in food during the breaking of fast could also have its complications, with the risk of hyperglycemia being a problem, despite being on medications or insulin, he said.
To avoid that, Prof Dr Nor Azmi recommended that people with diabetes should check their blood sugar levels during the four critical periods of the day to avoid further complications, that is before the Sahur period in the morning, two
hours after Sahur, at least two hours or immediately before breaking fast, and two hours after breaking fast.
Nonetheless, taking these precautions alone will not necessarily guarantee that everything is in check for diabetic Muslims. Therefore, Prof Dr Nor Azmi does not recommend that people with diabetes fast during Ramadan if they are not
able to take care of their disease by following proper advice regarding diet and medication.
Diabetic Muslims who have experienced any recent heart complications, as well as high blood pressure, are also discouraged from fasting, as well as those who frequently experience diabetic ketoacidosis or hypoglycemic conditions, and those who have infections.
Prof Dr Nor Azmi also does not recommend fasting for senior citizens who have diabetes and are living on their own or pregnant women who require frequent insulin shots, or individuals under the age of 12.
Consult your doctor
However, he advised diabetic Muslims who still desire to fast during the month of Ramadan to do so, provided they have consulted their doctor and have a clear understanding of the health risks involved, as well as of ways to avoid risks.
Prof Dr Nor Azmi highlighted that the lack of proper management during Ramadan heightened the severity of diabetic symptoms with a 14.1 per cent increase reported in cases of diabetes-related complications.
“Patients can minimise those risks by first learning how to identify and keep track of the complications that are typically associated with the disease, namely the three key ones – hypoglycemia, hyperglycemia, and dehydration.”
Symptoms for hypoglycemia are palpitations, disorientation and anxiety, uncontrolled shivering and sweating, paleness of the skin, and a general feeling of malaise, as well as excessive hunger.
Those who suffer from hyperglycemia will have symptoms that include frequent urination, excessive thirst, and lethargy, whereas dehydration shows symptoms such as an inability to concentrate, excessive thirst, dryness of the skin and tongue, and excessive weight loss that is more than three per cent of body weight within one day.
Further, he advised diabetic Muslims to frequently monitor their symptoms and make changes in their dietary intake.
“While the food consumed during Ramadan should not differ much from any regular balanced dietary meals, slight modifications will go a long way in reducing the risk of any complications arising from the disease,” he added.
To avoid complications through the 14-hour period (5.30 a.m. to 7.30 p.m.) without food, Prof Dr Nor Azmi encouraged patients to rehydrate themselves with enough water and avoid excess consumption of glucose or carbohydrate-laden foods when breaking fast.
There are other simple steps that one can take. For example, the ingestion of large amounts of foods rich in carbohydrates and fats for the sunset meal should be regulated.
Also, foods that contain complex carbohydrates should be encouraged at the predawn meals, which slow digestion and absorption, and food that contains moderate amounts of simple carbohydrates is best recommended to be consumed
during the sunset meal, he said.
From a number of treatment options available for type 2 diabetes during Ramadan, Prof Dr Nor Azmi highlighted a new and interesting treatment option from among incretin-based therapies called GLP-1 (glucagon-like peptide) agonist, which is a naturally occurring gut hormone that plays an important role in maintaining glucose levels in healthy individuals.
The good news is that the GLP-1 agonist reduces blood glucose only when levels are high, thus preventing the risk of hypoglycemia, and it as with exenatide and liraglutide, can lower blood glucose levels significantly without much risk of hypoglycemia.
Prof Dr Nor Azmi explained that due to its unique action on gut and satiety control centres, GLP-1 agonist could also reduce weight, an additional benefit as many type 2 diabetics are overweight or obese.
“The once daily option now available in GLP-1 agonist means there is no need of dose adjustments in the Ramadan period, as the risk of hypoglycemia is minimal,” he stressed.
Prof Dr Nor Azmi suggested that among conventional treatment of diabetes, metformin is the safest with low risk of hypoglycaemia.
New DPPIV inhibitors (various gliptins), he said, were also available in oral tablet form and could also reduce blood glucose albeit modestly, with low hypoglycemia risk. For those who are on insulin, newer insulin analogues have being shown to have less hypoglycemia risk than human insulin.
Other tips that Prof Dr Nor Azmi recommended for diabetics during the Ramadan period are that they must ensure adequate food intake during pre-dawn meals, not delay the breaking of fast, take medication as recommended, and avoid
excess eating or binging during the breaking of fast.
He also advised diabetic Muslims to make an effort to check their sugar levels as frequently as possible so they might have a general idea of the sugar and caloric content of any food before consumption.
The obligation of fasting is made easier and much more convenient for Muslims when steps and proper treatments were taken to ensure a smooth and hassle-free diabetic regimen throughout Ramadan, he said.