Diabetes and Ramadan

Review Article

Austin J Endocrinol Diabetes. 2016; 3(1): 1040.

Diabetes and Ramadan

 Okan Bakiner*

1Endocrinology and Metabolism Division, Baskent University School of Medicine, Turkey

2Baskent University School of Medicine, Family Practice, Turkey

*Corresponding author: Okan Bakiner, Endocrinology and Metabolism Division, Baskent University School of Medicine, Adana, Turkey

Received: April 18, 2016; Accepted: May 26, 2016; Published: May 31, 2016


Fasting during Ramadan, in the holy month of Islam, is an obligatory duty for healty adult Muslims. People who fast during Ramadan must abstain from eating, drinking, smoking and need to stop their medications from daybreak to sunset. Depending on the geographical settings and season, the duration of the daily fast may range from 12 to 20 hours. Diabetic patients who fasten in Ramadan may have some risks. Hypoglycemia, hyperglycemia, diabetic ketoacidozis, dehydration and venous thrombosis are posibble risks for fastening patients in diabetes. Physicians responsibility is to assess the patients andverify the high, intermediate and low risk groups. Likewise; physicians also need to identify the patients who can fasten during Ramadan, educate them and arrange their treatment. Following the observational studies and guidelines this review summarizes the management of a diabetic patient who wants to fasten during.

Keywords: Ramadan; Diabetes mellitus; Fasting


FOXO-1: Forkhead Box Protein O1; AMP: Adenosine Monophosphate; Sir-2, Sirt-1: Sirtulin Related Genes; IL-6: Interleukin 6; TNF: Tumor Necrosis Factor; CRP: C-Reactive Protein; HDL: High density Lipoprotein; LDL: Low Density Lipoprotein; GFR: Glomerule Filtration Rate; HOMA-IR: Homeostatic Model Assessment Insulin Resistance; SGLT-2: The Sodium/Glucose Cotransporter 2; GLP- 1: Glucagon-Like Peptide-1; DPP-4: Dipeptidyl Peptidase-4; NPH: Neutral Protamine Hagedorn


Muslims fast during Ramadan. It is one of the five pillars of Islam. Epidemiologic studies show that many of the diabetic patients want to fasten in the ramadan. Ramadan fasting for diabetics is associated with some risks. These are hypoglycemia, hyperglycemia, dehydratation and increased risk of thrombosis.Physicians need to identify the diabetic patients who are eligible to fasten and also arrange their medication. This review summarizes the management of diabetic patients who want to fasten in ramadan through the guidelines and observational studies on this topic.

The first section addresses hunger physiology, determining the effects of short term intermittant hunger on healthy people and diabetic patients also discussing the possible risks. Second section describes the management of diabetic patients who want to fasten during Ramadan.

The effect of fasting on healthy people and on diabeticpatients

Energy metabolism in humans: Energy utilization in humans takes places in two phases. First phase; known as the postprandial (absorbtive) phase covers the period between oral intake of food until it is totally absorbed from the gastrointestinal channel. It starts with intake of food and lasts approximately 4 hours. During this phase food is absorbed from the gastrointestinal channel and nutrients are utilized and stored. Also in this phase; carbohydrates are used acutely or stored in the liver in form of glucogen (glucogenesis), fatty acids are stored in the adipose tissue (lipogenesis) and aminoacids are transferred to the cells for protein synthesis. Insulin is primarily responsible for this phase. As this phase expires; the second phase known as the postabsortive period or the fasting period starts. Stored fuel is used to supply critical energy threshold. Stored glucogen is used at the first 6-24 hours (glucogenolysis). Fatty acid oxidation and ketogenesis is started(lipolysis). Then; gluconeogenesis occur in the liver also supplying the glucose levels for brain from aminoasids, lactate and glycerol (2-10 days). Insulinopenia, glucagonemia, sympatoadrenal discharge and in advanced stages cortisol are responsible for these effects. In advanced stages (12 hours-3weeks) stored fat is exhausted and energy is only supplied by gluconeogenesis from protein (starvation) [1].

The effect of short term or intermittant fasting on human physiology: Experimental studies show that during short term repeating fasting, hypotalamic neuropeptide Y levels decrase, insulin resistance of peripheric muscles decrases, insulin levels released from pancreas go down, insulin sensitivity in the adipose tissue increases, leptin levels decrease, adiponektin levels increase, plasma insulin like growth factor-1 levels decrease, cardiac parasempatic tonus increases, heart rate and blood pressure decreases, FOXO-1 levels decrease, AMP kinase levels increase and stress resistance of the cells increases [2]. In addition; in the cardiovascular system, infarct area gets smaller and in the postinfarct period cell apoptosis and miyocardial fibrosis decrease, p53 and p38 apoptotic gen expression on the cell level decrease and with Sir2, Sirt 1 gen expression increases, cell death slows down, and with decreases in levels of lL-6, TNF and CRP,inflammatory processes breaks down, and lipid profile improves with decreased tryglicerid levels and increased high density lipid profiles [3].

Metabolic effects of Ramadan fasting: Fasting during Ramadan is an obligatory duty for healthy adult Muslims. People who fast during Ramadan must abstain from eating, drinking, smoking and stop taking medications-if any from daybreak to sunset. Depending on the geographical settings and season, the duration of the daily fasting may range from 12 to 20 hours. Normally, people take three main meals daily. During Ramadan the number reduces to two, one large meal at sunset (iftar) and one light meal before dawn (suhur). The metaanalysis of 21 studies containing 531 male and 299 female subjects during Ramadan reveals an intermediate decrease in males body weight, mean body fat and body mass index which was not seen in females. Unlike females, males generally continue daily activity during ramadan and this was thought to be the reason for this difference. No waist and hip circumference changes were noted for both genders. Body weight loss for males were highest at the third week of ramadan but after ramadan returned to preramadan levels [4]. In males; a decrease in total cholesterol and tryglicerid levels was noted, besides HDLcholesterol increase in females and specific LDL cholesterol decrease for both genders was found. Ramadan fasting does not have a specific effect on renal functions of healthy population but on 31 patients with chronic renal failure a progress in GFRand a reduction in urinary sodium and protein release is noted [5]. On the other hand; another study on 15 chronic renal patients not under dialysis has shown an increase in renal tubular damage without a change in glomerular filtration rate [6]. A study which has assessed the glucose metabolism during Ramadan fasting on healthy people has demonstrated a specific reduction on fastening blood glucose andon insulin resistance measured with HOMAIR compared to preramadan period, also with a recovery on beta cell functions calculated with HOMA-beta at the fourth week of Ramadan [7]. However; in diabetic patients; increased glucogenolysis secondary to absolute insulin deficiency and hyperglycemia and risk of ketoacidosis due to glucogenolysis and ketogenesis, already present insulin resistance, the disruptive effects of current medications on insulin and counter insulin mechanisms and impairment in insulin resistance and increased gluconeogenesis secondary to loss of diurnal rhytm of cortisol altogether may inhibit the anticipated positive effects of Ramadan fasting and prepare ground for acute diabetic complications.

Possible risks for fastening patients in diabetes: EPIDIAR study conducted in 13 Islamic nations on 12914 diabetic patients has revealed that 43% of type 1 diabetic patients and 79% of type II diabetic patients have been fastening in Ramadan, which means about 55 million diabetics on earth have been fastening each year [8]. According to the data of this study, risk of hypoglycemia has increased 4.7 fold and 7.5 fold for type 1 and type 2 diabetics respectively. Decreased caloric intake, long hours of fasting (16-20 hours in summer), lack of glucogen storage due to insulin deficiency and resistance, the continous effects of insulin and secretogogs, and patients concerns of disturbing their fast with self glucose monitoring are main factors which increase the risk of hypoglycemia. Indeed the READ study which addresses Ramadan education for diabetic patients has revealed a 4 fold increase in hypoglycemia for the uneducated group [9]. Also according to EPIDIAR data, hyperglycemia risk with or without ketoacidosis that requires hospitalization has increased 5 fold and 3 fold for fastening type l and type ll diabetic patients respectively. The reasons for hyperglycemia are: increased calorie and simple carbohydrate intake, the effects of counterinsulin hormones, insulin deficiency, increased glucogenolysis, ketogenesis and gluconeogenesis, patients improper use of medications, and lack of self glucose monitoring. Another problem encountered in fastening diabetics is increased risk of dehydration. Insufficient fluid intake, liquid loss with perspiration especially in summer, osmotic diuresis secondary to hyperglycemia and side effects of medications (SGLT-2 inhibitors-osmotic diuresis, GLP-1 agonists-vomiting , metformin-diarrhea) are possible reasons for dehydration [10]. Finally hypercoagulability states, triggered by hyperglycemia and hypovolemia may induce risk of thrombosis and stroke, acute coronary events, serebral venous and sinus thrombosis and retinal vein occlusion [11,12].

Management of diabetic patients who wantto fasten inRamadan

Actual guidelines that contain data on observational and randomised studies and expert opinions regarding to diabetic patients who wish to fasten during Ramadan have been prepared [13- 15]. According to these guidelines patients who wish to fasten during Ramadan must be taken underassessment at least a few months in advance.The preliminary assessment consists of duration of diabetes, medications, comorbid conditions, diabetic vascular complications, hypo- hyperglycemic events, history of ketoasidosis and hypoglycemic coma, previous fasting history, life conditions, and assessment of self glucose monitoring. Blood pressure, body mass index must be taken and systemic and neuropatic examination must be made.HbA1c, blood glucose profile, renal functions, eye examination, urinary albumin creatinin rate, an electrocardiogram (further cardiac tests if necessary) must be assessed. A risk classification for a patient is obtained through this data which is divided into four groups.

Citation: Okan Bakiner and Akadli Kursad Ozsahin. Diabetes and Ramadan. Austin J Endocrinol Diabetes. 2016; 3(1): 1040. ISSN : 2381-9200