Ramadan can be a difficult time for those Muslim diabetics who want to fast and don’t know how to incorporate fasting into their diabetes diet.

We asked Pietermaritzburg-based dietician Sumaya Sooliman for some advice on managing diabetes during Ramadan and she gave us this fantastic information… Read on!

Ramadan is the ninth month of the Islamic calendar and is known as the month of believers. It is an opportunity for Muslims to purify their minds, bodies, heart and soul.

The important aim of Ramadan is also to experience what the poor feel and what it is like to be hungry so that we appreciate what our creator has given us. Fasting is compulsory for Muslims who have reached the age of puberty, are healthy and able to fast. Those who have conditions where fasting is seen as detrimental to health are exempt from fasting; however, this is entirely the individual’s decision. Diabetics fall under this category. There are however, many well controlled otherwise healthy diabetics who wish to fast. The following are guidelines to help those with diabetes to safely fast during Ramadan.

What is diabetes?

Diabetes is a condition where the body is unable to make enough insulin (Type 1 diabetes) or it is unable to use the insulin it makes effectively (Type 2 diabetes). This affects the way the food we eat is absorbed into the body to provide us with energy. These result in a build-up of glucose in the bloodstream called hyperglycaemia.

The symptoms of diabetes include excessive thirst, excessive urination, excessive hunger, unexplained weight loss or weight gain, fatigue, blurred vision and frequent infections that take long to heal.

Diabetes and the above symptoms can be controlled with medication, diet and exercise. Type 1 diabetics are treated with insulin injections, whilst type 2 diabetics are treated with oral tablets and sometimes insulin. A person with diabetes can live a perfectly, normal, good quality, healthy life if they are compliant with medication, diet and exercise.

Which diabetics can fast?

It must be mentioned that only those diabetics whose blood glucose levels are well controlled, compliant with medication and otherwise healthy can safely fast.

Type 1 diabetics on insulin are at a higher risk for fasting as compared to Type 2 diabetics. Type 2 diabetics on insulin are at a higher risk for fasting as compared to Type 2 diabetics on oral hypoglycaemic agents. Poorly controlled Type 1 or Type 2 diabetics as well as diabetics with heart or kidney disease are very high risk patients and should consider not fasting. Fasting increases the risk of hypoglycaemia, diabetic ketoacidosis and dehydration and patients may require hospitalisation.

However, currently in South Africa, with the fasts being just about 12 hours, well controlled diabetics can safely fast. Furthermore, if they follow the guidelines correctly and use the fast as a means of detox and putting the right foods into the body, it can also be very beneficial.

Sumaya Sooliman, Dietician

Fasting can improve weight management, result in weight loss and can be beneficial to improve insulin resistance and therefore improve the condition.

Before deciding to fast

It is important that the diabetic individual deciding to fast be aware of the risks associated with fasting and has had a thorough check up with the doctor to establish if it is safe for them to fast. Family support is imperative at this stage and it is important that the family understand the journey the patient will be undertaking. The family should also form part of the pre-Ramadan education sessions in order to guide and support the patient.

It is crucial that they are educated on blood glucose control, adapting medication, exercise, what to do if experiencing hyper or hypoglycaemia or dehydration and the appropriate diet to be followed in order to reduce the risks associated with fasting. Furthermore, it is vital that they are informed as to when it is necessary to break the fast to prevent further complications.

The individual can decide if they will be fasting the whole month or if they will be fasting on alternate days. It is also beneficial if the individual practices a few fasts prior to the start of Ramadan to establish if he/she will cope during Ramadan. Furthermore, the fasting diabetic must inform those around him/her that he/she is fasting.

A diabetic who is planning to fast must not have a fear of fasting. The same diet can be followed during Ramadan as during the rest of the year, the only difference is that meal times have changed and medication will have to be adjusted accordingly.

Sumaya Sooliman, Dietician

Simply put, for a diabetic, in Ramadan; the day and night are reversed. Hypothetically speaking, the iftar or sunset meal is like breakfast (breaking the fast); the meal from supper to after the evening prayers will be considered lunch and snacking and the sehri (pre-dawn) meal is considered as supper; so the fasting hours can be equivalent to the time when one is usually asleep at night and not eating.

Types of foods to eat during Ramadan

• Foods that are high in energy, yet nutritious such as nuts and dates
• Foods that keep one full for a longer time ie. high in fibre such as whole gains and cereals eg. brown bread, oats
• Fruits and vegetables to provide enough vitamins and minerals
• Meat, fish, chicken, lentils, milk, eggs and yoghurt as these are good sources of protein and also keep one full for longer
• Drink lots of water to prevent dehydration

Types of foods to limit during Ramadan

• Foods high in fat and sugar as these make you full very quickly and then hungry again soon after. They can result in hyperglycaemia (high blood sugar) immediately after eating and then hypoglycaemia (low blood sugar) later. They also make you sluggish so you get tired quickly and are low in vitamins and minerals eg. pies, samoosas,burgers , donuts and cakes.
• Drinks high in caffeine such as tea, coffee, fizzy drinks as this may cause dehydration

Suhoor/Sehri: The pre-dawn meal

At sehri it is important to eat foods that keep one fuller for longer. These foods include complex carbohydrates rather than refined starches and foods that are high in energy and protein. It is also important to drink water to keep you hydrated during the fasting day.

Example of a nutritious sehri

It is a good idea to start sehri with an energy dense fruit such as a banana. Thereafter, a bowl of wholegrain porridge such as oats or semolina, whole-wheat or bran cereals is suitable with low fat milk and a teaspoon of sugar or honey. It is a good idea to add a tablespoon of seeds (pumpkin, sunflower, sesame and linseeds) or nuts and muesli to the porridge to increase the energy and fibre content which will keep you fuller for a longer period of time. Thereafter 1 to 2 slices of brown or wholewheat/low GI bread with peanut butter or cheese is advised. Egg bread/French toast made with brown or wholewheat/low GI bread is also a good option.

One can drink water or fruit juice at sehri. Since mornings are going to be cold, a warm drink may be preferred. It is better to drink rooibos tea or Milo, Horlicks, Nesquik or hot chocolate rather than tea or coffee. If a powdered drink is desired, 3 level teaspoons of powder in a cup of low fat milk with no sugar is the recommendation.

It is advisable to end the sehri with a handful of unsalted nuts or almonds and up to 3 dates. The prophet Muhammad (peace be upon him (pbuh)) advised us on the excellent properties of dates and recommended dried dates for sehri as these are full of slow releasing energy that will sustain one during the day. Dates have a low GI between 35 – 55 and are therefore safe and ideal for diabetics.

Drink a little bit of water at sehri. It is crucial that a diabetic does not skip this meal as it could result in hypoglycaemia later in the day.

Sumaya Soolima, Dieticiann

Habits to avoid at sehri

Whilst there are foods to avoid, there are also certain bad habits that should be avoided at sehri. One should not stuff themselves for fear of feeling hungry during the fasting day. The above mentioned foods will not prevent hunger as this is the essence of fasting; but it will maintain energy levels so that we are able to function optimally. Avoid jumping into bed or lying down immediately after eating. This can make one nauseas, cause constipation and increase acid reflux and cause heartburn. It is advisable to wait 45 minutes to an hour after sehri before lying down. If you are someone who specifically battles with heartburn, sleep with the pillows elevated so you are not lying flat.

Iftar: The sunset meal (opening the fast)

It is important to open the fast with foods that are pure, whole and natural. After fasting the whole day and cleansing the body, it is advisable to continue with this process and consume good foods. It is prophetic teaching to open the fast with fresh dates as these are high in natural sugar and provide a burst of energy after going without food for the day. The prophet (pbuh) used to eat dates and cucumbers or dates and almonds together as they neutralise each other. Date is heat and cucumber is cool. It is advisable to open with dates and water.

Example of a nutritious iftar

The iftar table should be laid with dates, salad, fresh fruit and water. One can open the fast with up to 3 dates or half a cup of cut fruit and water and thereafter a soup with a slice of brown/whole-wheat or low GI bread. The traditional bowl of haleem (barley broth) or soup is beneficial as this warms the body after fasting.

Thereafter, one should break for the sunset prayer and return for supper. A traditional curry and rice meal cooked with minimal oil and served with a side salad or a vegetable is acceptable. Also grilled meals such as chicken, chops, steak or fish with roasted vegetables and salad or oven baked or air fried chips or baked or mashed potato is a good option. It’s important to ensure that vegetables or salad is served with the meal. Rice, whole-wheat pasta, brown roti and brown or whole-wheat breads or rolls are good options. It is also advisable to have a good variety of foods every day and alternate proteins ie. meat, chicken, fish as well as have meat free days eg. fish counts as meat free as well as lentils such as mung dhal. By having a good variety and combining starches, proteins and vegetables at meals, one is able to get all the nutrients they require in a short space of time. It is beneficial to drink water or ½ cup 100% fruit juice with supper.

Avoid foods that are high in fat and sugar and avoid overeating as this can result in hyperglycaemia (high blood sugar). These include high fat, deep fried foods such as samoosas, bhajias, pies, donuts and cakes.

Tea, coffee and fizzy drinks should also be limited at iftar time. Processed meats such a patties, polonies, sausages etc.should also be avoided. These foods are not only refined, high in fat and have low nutritional value; they cause constipation, bloating, stomach discomfort and heartburn. They also result in one filling up on these at the time of breaking fast and then not having space for more nutritious foods, therefore losing out on replenishing your nutrients after fasting. Furthermore, eating incorrectly at iftar and supper will affect you from performing the evening prayer optimally.

Habits to avoid at iftar

Avoid overeating and eating very fast. This is a sign of greed as well as will make you feel uncomfortable and sick. It is important that we thank the Almighty for blessing us with an abundance of food and a huge spread at our tables and remember those who don’t even break their fast because they have no food and bear in mind that for them, Ramadan does not end. It must be mentioned here that our prophet (pbuh) has mentioned: the stomach is the home of disease and abstinence from gluttony is the head of every remedy.

The prophet (pbuh) has also guided us to eat just to sustain ourselves: The son of Adam never fills a vessel worse than his stomach. The son of Adam only needs a few bites that would sustain him, but if he insists, one third should be reserved for his food, another third for his drink and the last third for his breathing.

The evening prayer (Taraweeh)

Try to catch up on water intake and hydrate yourself during evening prayers. Keep a bottle of water with you and drink as you take breaks between your prayers. It is more important as well as more achievable to catch up on water intake during the evening non-fasting hours as opposed to the pre-dawn meal.

After taraweeh, healthy desserts such as ½ a cup of fruit salad and ice cream, custard and jelly, strawberries and cream or the milk falooda is acceptable. Use low fat milk in preparation. A cup of almond milk (homemade badam milk or kheer), or rooibos tea with whole-wheat crackers and cheese or 2 rusks or 2 small biscuits is also acceptable. If one is not feeling for the above, then one or two medium sized fruit is also a good option and an excellent way to still get sufficient fruit intake.

Exercise

Normal daily activity that the diabetic individual usually engages in is sufficient and safe. However, excessive physical activity during fasting hours may lead to hypoglycaemia and dehydration. It is therefore safer to exercise two hours after the sunset meal. The taraweeh prayer is quite intense and can be considered a form of physical activity. Remember to drink lots of water during prayer intervals (rakaats).

Medication

It is crucial that you discuss your medication with your doctor before deciding to fast. Those on oral hypoglycaemic agents are at less risk than those taking insulin.

However, since the evening involves greater food intake, the medication dosage would be altered where the ratio is greater at night as compared to the morning.

Please ensure that you are aware of the correct dose and time of the medication during Ramadan as this determines your overall well-being during the month and your ability to fast.

Medication is individualised: there is no one size fits all so it is therefore of utmost importance that this be discussed with your doctor and both the doctor and family are aware that you will be fasting.

This cannot be stressed enough as mismanagement can be detrimental and even fatal.

Blood glucose monitoring and breaking the fast

Blood glucose levels should be monitored frequently, at least 2-4 times daily ie. before, during and after the fast. Checking blood glucose levels does not break the fast. If the blood glucose is less than 3.3 mmol/l or greater than 16.7 mmol/l; the fast has to be broken to prevent further complications.

What to do if hypoglycaemia occurs during the fast

Break the fast with 2-4 teaspoons of sugar in water (sugar water); ½ cup of regular soda (cooldrink) or ½ cup of fruit juice. Check the blood glucose levels again after 15 minutes and then have a wholesome snack such as a slice of brown bread with peanut butter/cheese or ½ cup of yoghurt with muesli or 1 cup of milk with a teaspoon of sugar or honey as these will restore and stabilise the blood glucose levels. Monitor the blood glucose levels every 15 to 30 minutes thereafter until it restores to normal.

As a rule, diabetics should always carry sweets in their handbags, pockets or in the car in the case of hypoglycaemia. Diabetics should take a break from fasting for a few days to recuperate if they have had a hyperglycaemic or hypoglycaemic episode.

Final thoughts

I would like to take this opportunity to wish all Muslims a blessed, prosperous and spiritually uplifting Ramadan. I would also like to commend those diabetics taking on the challenge of fasting during this month. May the Almighty grant you strength and reward you for your efforts.

Healthy Bran muffin recipe for sehri

Beat together:

2 cups milk
2 eggs
1t vanilla essence
½ cup oil, 1 ½ cup sugar

Mix together:

2 cups bran
2 ½ cup nutty wheat
1t bicarb
1 cup (carrots/apple/dates/pecans/mixed fruit/cranberries/muesli/almonds – your choice) *rub this into the dry mixture

*Add dry ingredients into beaten mixture. Beat well until everything is well mixed and evenly spread. Scoop into greased muffin pan and bake on 180 for about 20 minutes.

Healthy vegetable soup for iftar

½ cup 4 in 1 soup mix (1/4 cup pea dholl, ¼ cup pink lentils, ¼ cup barley, ¼ cup crushed wheat)
2 medium potatoes
2 medium tomatoes
2 large carrots
1 small onion
2 medium turnips
2t salt
½t black pepper

*Soak dholls overnight. Boil all ingredients together and liquidise. Garnish with greens.

Time saving tip:
Make a big amount of soup on a weekend and freeze in smaller containers, and then take out, thaw and simply heat on the day you want to serve it.

Download more information about diabetes and Ramadan

What to read next?

The Type 1 Diabetes Guidebook – for parents. This practical, helpful guide was written to help parents whose children have just been diagnosed with Type 1 diabetes, packed with advice from other parents who understand.

Sweet Life is awarded an international diabetes grant: Panorama launches The T1D Community Fund, and announces first cohort of global grantees – Sweet Life Diabetes Community is one of them!

Diabetes during Ramadan – a guide: If you have diabetes, it’s important to understand the effects of Ramadan fasting on your blood sugar, which is why Sanofi put together this helpful guide. Ramadan Mubarak to all our community members who are observing Ramadan!

 

References

• Al-Arouj M (2010). Recommendations for Management of diabetes during Ramadan. URL: care.diabetesjournals.org
• Managing diabetes during Ramadan – Diabetes UK. URL: https://www.diabetes.org.uk>ramadan
• Joslin Diabetes Center (2016). Ramadan and Diabetes. joslin.org
• Ibrahim M (2015). Recommendations for management of diabetes during Ramadaan: update 2015. British Medical Journal. URL: drc.bmj.com
• Journal of Endocrinology, Metabolism and Diabetes of South Africa (JEMDSA) (2012). Management of diabetes during Ramadaan. JEMDSA 2012; 17(2): S88-S90.
• Imam Ibn Qayyim Al-Jauziyah (1999). Healing with the Medicine of the Prophet (pbuh). Darussalam Publishers and Distributers: Darussalam, Riyadh, Saudi Arabia.

Photos by Abdullah Arif, kateryna-hliznitsova , Alisher Sharip , cleo stracuzza, Anna Pelzer Priscilla Du Preez, Nathalie Jolie on Unsplash