Ramadan and Diabetes

Fasting and Feasting Safely With Diabetes

Diabetes is one of the medical conditions which exempts some people from fasting. Health and the control of blood glucose levels are closely linked with diet, meal timings and medication, in people with Diabetes. However having diabetes does not mean you cannot fast. This information leaflet gives advice on what to do if you have diabetes and want to fast, so that you can do so as safely as possible.

If you are in any doubt about what you should do with your treatment while fasting, contact your Diabetes Specialist Nurse or GP.

Group 1: People controlling their diabetes with careful diet and exercise (no diabetes medication)

Continue to be careful with your diet and you can fast safely during Ramadan. If you are overweight, you can lose weight during the Holy Month, which can improve your diabetic control.

Divide your food into 2 meals – Sehri/ Suhoor and Iftar.
Eat small amounts of starchy carbohydrate foods such as cereals, basmati rice, chapatti or naan at both meals.
Include fruits, vegetables, lentils/dhal and yoghurt in your meals.
Only have small amounts of sugary and fatty foods such as, baklawas, Asian sweets, chocolates
Avoid very fatty fried foods like samosa, spring rolls, pakora, chips or dumplings
Stick to sugar free or ‘diet, lite/zero’ drinks, ‘no added sugar’ dilute drinks and herbal teas. If you need to sweeten your hot drinks like tea or coffee you can use artificial sweetener.
You may feel tired when fasting during Ramadan, so although it is important that you continue your daily activity and prayer, try to rest at some point in the day

Group 2: People controlling their diabetes with diet, exercise AND TABLETS

It is important that you follow the same advice as Group 1 regarding diet and resting.

For people taking METFORMIN
If you feel unwell during the fast taking Metformin, you can consider reducing the dose during Ramadan. Most people should continue to take them, the largest dose should be taken at Iftar, so that they work when you are eating.

For people taking GLICLAZIDE, GLIPIZIDE, GLIMEPIRIDE & GLIBENCLAMIDE (with or without Metformin)
These tablets work for a whole day and can cause your blood glucose to go low (hypoglycaemia) during the day when you are fasting, which could make you feel ill. There are other tablets (such as Tolbutamide and Repaglinide), which wear off more quickly and are more suitable for you to take with a meal, when fasting.

People taking PIOGLITAZONE (with other tablets or insulin)
These tablets are usually taken in the morning. They can sometimes cause low blood glucose if you are fasting, so it is best to take the largest dose at Iftar.

People taking SITAGLIPTIN, VILDAGLIPTIN OR SAXAGLIPTIN tablets
These tablets are needed once daily. They are often taken with other tablets for diabetes. No changes are required if these tablets are taken alone or with metformin. The dose of these tablets rarely needs to be changed during Ramadan.

People taking EMPAGLIFLOZIN, DAPAGLIFLOZIN or CANAGLIFLOZIN tablets
These tablets are needed once daily. They are often taken with other tablets for diabetes. No changes are required if these tablets are taken alone or with metformin. The dose of these tablets rarely needs to be changed during Ramadan

If you are in doubt what to do with your tablets when fasting, please discuss this with your diabetic nurse or GP

Group 3: People controlling their diabetes with diet, exercise AND INSULIN

It is important that you follow the same advice as Group 1 regarding diet and resting

People taking One Injection per Day with or without Metformin
If taking a once daily injection of long acting insulin such as Lantus or Levemir, take it as usual. If after a few days of fasting you are experiencing blood glucose levels of 4 or less (hypos) during the day, you could reduce the dose of insulin by 10%.

If you have to cut back your insulin dose during Ramadan, you should discuss what dose you will need in future with your GP or Diabetes Specialist Nurse after Ramadan finishes.

People taking Two Injections per Day with or without Metformin
If taking twice daily injections of pre-mixed insulin i.e. Humalog Mix 25, Novomix 30, Humulin M3, Insuman Comb 25; there is a problem because most of the insulin works during the day and could make you go hypo when fasting.

The best way around this is to change to a different insulin regimen (called a basal/ bolus regimen), well before Ramadan starts.

An alternative is to change to a premixed insulin with a smaller long acting component (such as Insuman Comb 50 or Humalog Mix 50 ) so there will be less insulin around during the day. This will need to be taken with breakfast and evening meal before Ramadan starts. When Ramadan starts, take your usual dose with your largest meal at Iftar. If you decide to take a smaller meal before Suhoor, you will need a much smaller dose with that meal.

The last alternative is to under dose with insulin, cutting your dose by 10%, but this will not keep the diabetes under good control. Please seek medical advice if your glucose levels are too high (higher than 17mmol) or too low (less than 4mmol).

People taking Three Injections per Day
If you are on a three times daily mixed insulin you will need to miss out the lunchtime dose, because you will not be eating then. But take the other doses, with meals.

Remember to go back to your normal doses after Ramadan finishes

People taking four Injections per Day
If you are on a basal/ bolus regime (4 injections per day), you should take your long acting as normal.

Take your rapid acting (meal time) insulin only when you eat. If your meal is higher in carbohydrates than normal you may need to increase this dose.

One way to check if you have given correct amount is to test 2hours after eating. If your result is under 8.5 mmol/l you have estimated correctly.

If you are in doubt about what to do with your medication when fasting, discuss this with your Diabetes Nurse, Doctor, or GP.

Group 4: People taking EXENATIDE (Byetta)once weekly or twice daily, Dulaglutide (Trulicity) once weekly or LIRAGLUTIDE (Victozia) once daily or Semaglutide (Ozempic) once weekly, with or without other medications.

It is important that you follow the same advice as Group 1 regarding diet and resting.

There is usually no need to change the injection.

Testing blood glucose when taking tablets, insulin, Byetta and fasting
It may be a good idea to check your blood glucose more often when fasting to make sure it is not rising too high (more than 10 mmol/l) or dropping too low (less than 4 mmol/l). If your results worry you and you don’t know what to do, contact your Diabetes Nurse, Doctor, or GP.

You will probably need the help of your Diabetes Nurse or Doctor to change your insulin or timings, so please contact them for advice well in advance of the next Holy Month.

If you fast and are taking insulin, it is important to check your blood glucose frequently to make sure you are not going ‘hypo’ (less than 4 mmol/l) or that your blood glucose is not rising too high (more than 10 mmol/l).

Ramadan: When To Break Your Fast

If blood glucose is less than 4.0 mmol/l, even before sunset
If blood glucose is less than 4.0 mmol/l, in the first few hours after the start of the fast
If blood glucose levels are higher than 16 mmol/l

Hypoglycaemia (blood glucose less than 4)

Signs and symptoms – sweating, shaking, dizzy, palpitations, pins and needles around the mouth, double vision, hunger pangs, slurred speech, odd behavior, confusion, drowsiness.
Reasons for hypoglycemia – taking too many diabetes tablets or too much insulin and not balancing them with food, delaying or missing meals, more exercise than normal.

If you have a hypo when fasting, you should break this promptly to avoid the hypo getting worse and making you unwell

Hypo Treatment

Take fasting acting glucose (15g carbohydrate) as per hypo leaflet, wait 15 minutes to allow the fast acting glucose to be absorbed. If you can please test your blood glucose after 15minutes to ensure that it is above 4mmol/mol.
If your blood glucose is not above 4 mmol/l, please take some more fast acting glucose and wait 15minutes.
Once your blood glucose is above 4mmol/l, then take something starchy to eat, to keep your blood sugar up as recommended in the hypo leaflet.

Try to work out why you had a hypo.

Was it because you fasted and didn’t change your diabetes treatment?
Was it because you were doing hard physical work and not resting?

People At Risk When Fasting

If you fast when pregnant, and have diabetes there are risks for yourself and your baby.
You are at risk if you have other illnesses as well as diabetes.
You are at risk if your diabetes is not well controlled and your blood glucose swings up and down.
You are at risk if you do not take the right diabetes treatment when fasting.

How To Contact The Diabetes Specialist Nurses At The Diabetes Centre

Tel 020 8510 5920
020 8510 5555 bleep 065

Monday - Friday; 09.00 - 17.00 hours.

Published: Mar 21, 2023