Many Muslims with medical conditions such as diabetes observe a fasting period during Ramadan despite being religiously exempted from doing so. We break down the health risks, as well as preventive measures, to ensure a safe and healthy fasting season.
MILLIONS of Muslims in Malaysia are now celebrating the holy month of Ramadan, including those with medical conditions like diabetes.
In Islam, Ramadan is considered to be the most blessed and spiritually-beneficial month of the year.
For this reason, many observe a fast from dawn to dusk throughout the month, during which they must abstain from eating, drinking and smoking, amongst other practices.
There are however, no restrictions on the amount of food or drink they can consume at night.
According to religious tenets, fasting is intended to teach a person patience, humility and self-control.
This practice is also thought to be good for health, and provides a yearly routine of spiritual cleansing for Muslims.
Many Muslims with legitimate health concerns also fast despite being religiously exempted from doing so – some even going against their doctor’s advice.
Hence, it is imperative for medical professionals, and even more so for those who are fasting, to be aware of the potential risks associated with fasting, and take steps to fast in a safe and healthy manner.
Diabetes is a condition that causes a person’s blood sugar level to rise too high.
It occurs when the body does not produce enough insulin to function properly, or when the body’s cells do not react to insulin. This is known as insulin resistance.
Type 2 diabetes is the most common type of diabetes and affects up to 90% of diabetic patients around the world.
It usually affects those over the age of 40, although increasingly younger people are also being affected.
Its growing prevalence is associated with rapid cultural and social changes, and is often attributed to unhealthy lifestyle and behavioural patterns such as a poor diet coupled with physical inactivity.
In 2010, the National Health and Morbidity Survey revealed that an estimated 3.4 million Malaysians suffer from diabetes.
The survey showed an increase in diabetic cases among Malaysians aged 30 and above, from 8.3% in 1996, to 14.9% in 2006. This marks an 80% increase over a period of just 10 years.
The same survey revealed an even more dramatic increase in diabetic cases among the nation’s youth. Between 1996 and 2006, the number of diabetic cases in Malaysians aged 18 years and above rose from 4.4% to 14%, a 200% increase in just a decade.
More alarmingly, it is believed that an estimated one-third (or 36%) of the diabetic population remains undiagnosed.
Fasting is not meant to create excessive hardship on the individual, but Muslims who are diabetic may face significant challenges in managing their condition, as fasting requires abstinence from all foods, fluids, oral medications, as well as IV fluids, which may be required to keep their blood sugar level in check.
Among the problems to look out for include:
Hypoglycaemia (low blood sugar)
Low blood sugar is a well-known risk associated with daytime fasting, especially for diabetic patients. It occurs when there is too much insulin and not enough sugar (glucose) in your blood.
If left untreated, low blood sugar can lead to serious medical problems, including loss of consciousness, and convulsions or seizures that require emergency treatment.
Professor Dr Nor Azmi Kamaruddin, head of the diabetes and endocrine unit at Universiti Kebangsaan Malaysia (UKM), explains that factors such as taking too much insulin or other diabetes medications, skipping a meal, or exercising harder than usual can cause low blood sugar in diabetics.
Not eating enough during sahur, the meal consumed before dawn, can increase the risk of hypoglycaemia, he explains.
The logic behind this is simple. Most diabetic patients are required to take insulin or other diabetic medications to decrease their blood sugar levels. However, consuming less calories than what your body needs naturally will lower your sugar levels. This, compounded with the use of insulin or diabetic medications, could cause blood sugar to plummet to dangerous levels.
“Most people do not eat enough during sahur, because they are not used to eating at that hour. Hence, appetite tends to be poor,” says Prof Azmi.
“Diabetics, in particular, need to consume the same amount of food they usually consume, to maintain a healthy blood sugar level.”
He stresses that reduction of insulin or medication is not recommended because if you do not have enough insulin to cover the extra sugar in your blood, ketoacidosis can occur.
Ketoacidosis itself is a severe, life-threatening condition that requires immediate treatment. Symptoms include nausea, vomiting, abdominal pain, rapid breathing, and in some cases, unconsciousness.
Hyperglycaemia (high blood sugar)
Conversely, high blood sugar also affects people with diabetes. Contributing factors include excessive food intake, illness, and not taking enough glucose-lowering medication.
High blood sugar can become severe and result in serious complications such as diabetic coma, which requires emergency care. In the long term, persistent hyperglycaemia, even if not severe, can lead to complications affecting the eyes, kidneys, nerves and heart.
During Ramadan, most people usually consume two meals per day - one before sunrise and one after sunset.
“However, some people have the tendency to binge-eat when they break fast. That’s when the problem arises,” says Prof Azmi.
“When you starve yourself for some 14 hours, and then consume a significant amount of food, your blood sugar levels will shoot up if you’re diabetic.”
“This occurs especially when people go to bazaars hungry. They tend to overbuy, and subsequently overeat.”
When you have diabetes, excess glucose builds up in your blood. As a result, your kidneys have to work harder to filter and absorb the excess sugar.
If your kidneys can’t keep up, the excess sugar is excreted through your urine, along with fluids drawn from your tissues. This causes frequent urination, which may leave a diabetic dehydrated and constantly thirsty. As they drink more fluids to quench their thirst, they will urinate even more.
This is where the problem arises. Says Prof Azmi: “During Ramadan, diabetic patients tend to suffer from dehydration because they don’t drink enough water to replenish the fluids that have been lost.
“To make things worse, Malaysia is situated in the tropics. On average, we lose up to half a litre of sweat everyday due to the heat.
“Those who work outdoors could lose over a litre every day.”
Fasting tips for diabetics
During Ramadan, your regular day-to-day dietary habits get thrown out the window. Health problems can arise from an insufficient diet or as a consequence of overeating.
To avoid this, it is essential for diabetic patients to maintain a healthy and balanced diet throughout the holy month. The aim should be to maintain a consistent body mass.
At the predawn meal, consuming foods rich in “complex” carbohydrates (slow-digesting foods) is advisable because of the delay in digestion and absorption, which keeps you feeling fuller for longer.
In addition, increase your fluid intake during non-fasting hours to avoid dehydration.
When breaking fast, Prof Azmi advises diabetic Muslims to start off with a glass of water, before moving on to dishes, starting from vegetables, protein, and finally to carbohydrates, to avoid overeating.
Ingesting large amounts of foods rich in carbohydrates and fats should be avoided, he says. “About 70-80% of the Asian diet consists of rice. However, the high glycaemic index (GI) in rice could cause blood sugars to spike.
“Also, try to avoid sweetened or carbonated drinks. You might also want to go for whole fruit options instead of fruit juices.
“Ingestion of fruit juices leads to a rapid absorption of glucose in the bloodstream, resulting in a sudden spike in blood sugar.
“In comparison, eating whole fruits involves processes such as chewing and digestion. This will result in a more gradual and stable increase in blood sugar.”
Frequent monitoring of sugar levels and medication
It is important for diabetic patients to monitor their blood sugar levels multiple times a day.
This is especially critical for type 2 diabetes patients who require insulin.
Mobile applications such as Ramadan, Diabetes and Me allow diabetic patients to keep track of their blood sugar levels throughout the day.
Developed by MSD, the app (which is currently only available on IOS devices) feature a blood sugar tracker that offers an easy and convenient way to monitor your daily blood sugar levels.
Meanwhile, those who are on oral medication may have to adjust the dosage or switch to short-acting medication, which can be taken along with their main meal of the day.
Similarly, patients who are on insulin will need to switch to a twice-a-day regime of short-acting insulin, with the larger dose timed before the main evening meal.
Normal levels of physical activity may be maintained. However, Prof Azmi advises against strenuous exercise, as it may lead to a higher risk of hypoglycaemia.
“If a diabetic patient has already been exercising regularly, he should continue, but stick to mild or moderate-intensity exercises,” he says.
“I would suggest exercising just before the break of fast, rather than in the morning, so they will be able to recover from their workouts by replenishing their bodies with food.”
He also points out that diabetic patients should try to avoid sun exposure to avoid further fluid loss.
Pre-Ramadan medical assessment
Ideally, all diabetic patients who wish to fast during Ramadan should undergo a medical assessment and engage in an education programme to undertake the obligation as safely as possible.
The American Diabetes Association recommends that people with type 2 diabetes undergo a medical assessment at least two months prior to fasting.
South-east Asian guidelines for management of endocrine disorders during Ramadan advise planning for the period at least three months in advance.
During this assessment, individual patients need to understand the potential risks they may face if they decide to fast.
Specific changes in diet or medication regimens should be tailored to a patient’s needs, so they can fast on a stable and effective programme.
Such assessments should also extend to those who do not wish to fast due to the heightened risk of hypo- and hyperglycaemia.