Recommendations for Management of Diabetes During Ramadan

S ince our last publication about diabetes and fasting during Ramadan (1), we have received many inquires and comments concerning important issues that were not discussed in the previous document, including the voluntary 1to 2-day fasts per week that many Muslims practice throughout the year, as well as the effect of prolonged fasting (more than 18 h a day) in regions far from the equator during Ramadan when it occurs in summer—a phenomenon expected to affect millions worldwide for the next 10–15 years. Since 2005, there have been substantial additions to the literature, including two studies examining the effect of structured education and support for safe fasting, both of which had promising results (2,3). In addition, new medications, such as the incretin-based therapies, have been introduced with less risk for hypoglycemia. According to a 2009 demographic study, Islam has 1.57 billion adherents, making up 23% of the world population of 6.8 billion, and is growing by 3% per year (4). Fasting during Ramadan, a holy month of Islam, is a duty for all healthy adult Muslims. The high global prevalence of type 2 diabetes—6.6% among adults age 20 –79 years (5)— coupled with the results of the population-based Epidemiology of Diabetes and Ramadan 1422/2001 (EPIDIAR) study, which demonstrated among 12,243 people with diabetes from 13 Islamic countries that 43% of patients with type 1 diabetes and 79% of patients with type 2 diabetes fast during Ramadan (6), lead to the estimate that worldwide more than 50 million people with diabetes fast during Ramadan. Ramadan is a lunar-based month, and its duration varies between 29 and 30 days. Muslims who fast during Ramadan must abstain from eating, drinking, use of oral medications, and smoking from predawn to after sunset; however, there are no restrictions on food or fluid intake between sunset and dawn. Most people consume two meals per day during this month, one after sunset and the other before dawn. Fasting is not meant to create excessive hardship on the Muslim individual according to religious tenets. Nevertheless, many patients with diabetes insist on fasting during Ramadan, thereby creating a medical challenge for themselves and their health care providers. It is increasingly important that medical professionals be aware of potential risks associated with fasting during Ramadan and with approaches to mitigate those risks. These issues are rapidly becoming global issues, not only in Indonesia, Pakistan, and the Middle East, but also in North America, Europe, and Oceania. Although recommendations for management of diabetes in patients who elect to fast during Ramadan were proposed in 1995 at a conference in Casablanca (7), our previous document was prompted by the EPIDIAR study (6). The purpose of this review is to evaluate new data that has emerged since the publication of the 2005 article and to refine our recommendations. In this revised document, we continue to avoid use of the terms “indications” or “contraindications” for fasting because fasting is a spiritual issue for which patients make their own decision after receiving appropriate advice from religious teachings and from health care providers. However, we emphasize that fasting, especially among patients with type 1 diabetes with poor glycemic control, is associated with multiple risks.