Practical Guide to

Diabetes Management
in Ramadan

MINISTRY OF HEALTH
MALAYSIA

MALAYSIA ENDOCRINE
& METABOLIC SOCIETY

Practical Guide to Diabetes

Management in Ramadan
Table of Contents
FOREWORD..................................................................................................................................... i
PREFACE......................................................................................................................................... ii
OBJECTIVES.................................................................................................................................... iii
WORKING COMMITTEE................................................................................................................. iv
EXTERNAL REVIEWERS................................................................................................................... v
SUMMARY OF TREATMENT ALGORITHM...................................................................................... vi
SECTION 1 BACKGROUND..............................................................................................................1
SECTION 2 PATHOPHYSIOLOGY OF FASTING DURING RAMADAN..................................................3
SECTION 3 MEDICAL BENEFITS OF FASTING DURING RAMADAN..................................................7
SECTION 4 RISKS OF FASTING IN DIABETES DURING RAMADAN....................................................9
SECTION 5 PATIENTS WHO ARE AT RISK OF DEVELOPING COMPLICATIONS
DURING FASTING......................................................................................................11
SECTION 6 PREPARATION PRIOR TO RAMADAN...........................................................................15
SECTION 7 SELF-MONITORING OF BLOOD GLUCOSE DURING RAMADAN...................................19
SECTION 8 LIFESTYLE AND DIET MANAGEMENT DURING RAMADAN..........................................23
SECTION 9 ORAL ANTI-DIABETIC THERAPY DURING RAMADAN..................................................27
SECTION 10 INSULIN THERAPY DURING RAMADAN....................................................................31
GLOSSARY OF TERMS...................................................................................................................35
ACKNOWLEDGEMENTS............................................................................................................... 35
SOURCES OF FUNDING.................................................................................................................35

FOREWORD BY
THE DIRECTOR GENERAL OF HEALTH OF MALAYSIA
Many people around the world observe fasting as an important religious ritual. Healthy Muslims
are obligated to fast during the Holy Month of Ramadan, while those suffering from poorly
controlled diabetes or with major diabetes-related complications are exempted from doing so.
However due to strong personal beliefs, many of them still fast during Ramadan. Malaysia is one
of the countries with a high prevalence of diabetes with an estimated 1.2 million Malaysians who
have high blood sugars. Patients with diabetes who fast during Ramadan will require additional
attention by their healthcare providers. There are international and local clinical practice
guidelines on overall diabetes management available but practical guidelines on managing
diabetes particularly during Ramadan are limited.
In line with this, several endocrinologists from the Ministry of Health (MOH) and Ministry of
Education (MOE) have come together to form a working committee, dedicating their time
working together diligently to develop a practical guide to diabetes management during
Ramadan that will be relevant for Malaysian healthcare providers. I would like to acknowledge
the efforts taken by the working committee and to congratulate them on the development of
this practical guide which will assist healthcare providers particularly primary care physicians
in ensuring safe and optimal management of patients with diabetes during periods of fasting
particularly during Ramadan.
This practical guide is an addition to the collaborative milestones between MOH and the
Malaysian Endocrine & Metabolic Society (MEMS). With it in place, I believe our patients will
benefit from optimised treatment and management of their diabetes when they are fasting
during Ramadan. Hence I would like to urge all healthcare providers to fully utilise this practical
guide to further improve the quality of diabetes care in Malaysia during Ramadan period for the
lasting benefit of our patients.

Datuk Dr. Noor Hisham Abdullah

Director General of Health Malaysia

PREFACE
In Malaysia, an estimated 61% of the population practice Islam as their religion. One of the five
pillars of Islam is to fulfill the annual fasting during the holy month of Ramadan. In those with
illness, fasting is exempted but the majority of Muslims with diabetes will eagerly fast during
Ramadan. Muslims may also practice the non-obligatory fast during the non-Ramadan period
and some non-Muslims may also practice fasting for either religious or health reasons.
There is a concern that fasting among those with diabetes may increase risk of acute diabetesrelated complications such as hypoglycaemia, hyperglycaemia and dehydration. It is generally
observed that there are higher rates of emergency department admissions and hospitalisation
for diabetes emergencies among those with diabetes who fast during Ramadan.
Therefore it is important for clinicians and health care providers to recognise and provide
appropriate advice to those with diabetes having high risks for complications during fasting.
With structured patient education and individualised adjustments of lifestyle and medications
performed well in advance, most Muslims with diabetes can achieve acceptable metabolic
control while fasting, having better confidence in self-management and thus, avoiding the known
serious complications previously described.
This practical guide has been developed to provide a clear and concise approach to all health care
providers regarding the management of diabetes during fasting, particularly in Ramadan. I hope
it will help to ensure that those with diabetes may practice fasting safely, free from adversity and
be able to experience the many potential health benefits of fasting in addition to the spiritual
fulfillment gained.
Finally, I would like to express my gratitude to everyone involved in the development of this
practical guide and especially to the members of the Working Committee for their support and
contribution.

Dr. Zanariah Hussein

Chairperson
Working Committee
ii

OBJECTIVES
The aim of the practical guide is to assist health care providers, particularly
primary care physicians in ensuring safe and optimal management of
patients with diabetes during periods of fasting as in Ramadan.

Clinical Questions
This practical guide aims to address the following clinical questions:
1. What are the benefits and risks of fasting?
2. Who are at risk to fast?
3. How to screen and educate patients with diabetes prior
to Ramadan?
4. What are the glycaemic targets during Ramadan?
5. How to monitor glycaemia in patients during Ramadan?
6. How to optimise lifestyle and anti-diabetic therapy?

Target Population
This practical guide is applicable to adults with diabetes intending to fast
as in Ramadan.

Target Group
This practical guide is meant for all health care professionals involved in
the management of patients with diabetes mellitus, both in primary care
and hospital care.

iii

WORKING COMMITTEE
CHAIRPERSON

ADVISOR
Dr. Zanariah Bt Hussein
Consultant Endocrinologist,
Hospital Putrajaya,
Putrajaya

Prof. Dato Paduka Dr. Wan

Mohamad Wan Bebakar
Senior Consultant Endocrinologist,
Hospital Universiti Sains Malaysia,
Kelantan

MEMBERS (Alphabetical Order)

Dr. Ijaz Bt Hallaj
Rahmatullah

Dr. Masni Mohamad

Dr. Nor Azizah Aziz

Dr. Nor Shaffinaz Bt Yusoff

Azmi Merican

Consultant Endocrinologist,.
Hospital Raja Permaisuri Bainun,
Perak

Consultant Endocrinologist,.
Hospital Pulau Pinang,.
Pulau Pinang

Consultant Endocrinologist,.
Hospital Sultanah Bahiyah,.
Alor Setar

Dr. Norhaliza Mohd Ali

Dr. Norhayati Bt Yahaya

Consultant Endocrinologist,.
Hospital Sultanah Aminah,.
Johor Bahru

Consultant Endocrinologist,
Hospital Raja Perempuan Zainab II,
Kelantan

Dr. Nurain Mohd Noor

Dr. Wan Mohd Izani Wan

Mohamed

Consultant Endocrinologist,
Hospital Putrajaya,.
Putrajaya

Prof. Madya Dr. Norasyikin

Bt A. Wahab

Consultant Endocrinologist,.
Pusat Perubatan Universiti
Kebangsaan Malaysia,.
Kuala Lumpur
iv

Consultant Endocrinologist,
Hospital Putrajaya,.
Putrajaya

Consultant Endocrinologist,
Hospital Universiti Sains Malaysia,
Kelantan

EXTERNAL REVIEWERS
Y. Bhg. Datin Dr. Rugayah Bakri

Head, Malaysian Health Technology Assessment Section (MaHTAS).

& Deputy Director, Medical Development Division.
Ministry of Health, Malaysia

Prof. Dato Dr. Mafauzy Mohamed

Director of Campus / Professor of Medicine,.

Senior Consultant Endocrinologist,.
Hospital Universiti Sains Malaysia,.
Kelantan

Prof. Dr. Nor Azmi Kamaruddin

President,.
Malaysian Endocrine and Metabolic Society (MEMS),.
Senior Consultant Endocrinologist,.
Pusat Perubatan Universiti Kebangsaan Malaysia,.
Kuala Lumpur

Dr. Feisul Idzwan Mustapha

Public Health Physician,.
Disease Control Division,.
Department of Public Health,.
Ministry of Health Malaysia,.
Putrajaya

Dr. G. R. Letchuman

Senior Consultant Physician,.

Hospital Raja Permaisuri Bainun,.
Perak

Dr. Mastura Hj. Ismail

Consultant Family Medicine Specialist,.

Klinik Kesihatan Seremban 2,.
Negeri Sembilan

(The following external reviewers provided feedback on the draft.)

v

SUMMARY OF TREATMENT ALGORITHM

Pre-Ramadan medical review

Performed 12 months before Ramadan
Approach should be individualised
Assessment of glycaemic control, blood pressure, and lipids

Evaluate risk of developing complications

during Ramadan

Moderate risk
Low risk

Structured Ramadan-focused patient education

Meal planning and dietary advice with a dietitian
Appropriate timing and intensity of exercise
Blood glucose monitoring
Knowing when to end the fast
Recognising and managing acute complications

Treatment adjustments
Changes to diabetes medication regimens:
Treatment choice
Timing and frequency of dosing
Dosage adjustments

Follow-up is essential after Ramadan

HbA1c, blood pressure, lipids
Readjustment of medications where appropriate
Revert back to pre-Ramadan treatment regimen
vi

Very high risk

High risk

Advised to abstain
from fasting

Section 1
BACKGROUND

SECTION 1 BACKGROUND
A few religions worldwide practice the fasting ritual. Ramadan fasting is observed by Muslims
worldwide as fasting from dawn until dusk daily for 29 30 days. Non-Ramadan fasting is
undertaken by Muslims and people of other faith as either a single day or a few consecutive days
of fasting. Due to Malaysias location near the Equator, annual Ramadan fasting in Malaysia is
between 12 14 hours daily.
Among the benefits of fasting apart from heeding the Creators order is to teach self-restraint and
discipline as well as resting and cleansing the alimentary tract. The call to fast during Ramadan
for a healthy Muslim is stated in the holy Quran, where there is also a clear guide on individuals
who are exempted from fasting which includes those with chronic diseases such as diabetes
mellitus. (Surah Al Baqarah Verse 184-185)
Fasting in certain individuals with diabetes may be associated with adverse outcomes; hence
they are not obliged to fast.1 However, many diabetic patients choose to fast as shown in the
Epidemiology of Diabetes and Ramadan (EPIDIAR) study.1 Managing a Muslim patient with
diabetes during Ramadan continues to be a challenge for healthcare professionals.2
The adverse outcomes during fasting include dehydration, hypoglycaemia and hyperglycaemia.2,3
In a Malaysian study, diabetic patients with tight glycaemic control as well as the elderly were
found to have a higher risk of developing hypoglycaemia.4
As a diabetic patient undertakes fasting, pre-fasting education and planning is of paramount
importance to lower the incidence of adverse outcomes associated with fasting.

References
1. Salti I, Bnard E, Detournay B, et al. A population-based study of diabetes and its characteristics during the fasting
month of Ramadan in 13 countries: results of the epidemiology of diabetes and Ramadan 1422/2001 (EPIDIAR) study.
Diabetes Care. 2004; 27(10): 2306-2311.
2. Al-Arouj M, Assaad-Khalil S, Buse J, et al. Recommendations for management of diabetes during Ramadan: update
2010. Diabetes Care. 2010; 33(8): 1895-902.
3. Karamat MA, Syed A, Hanif W. Review of diabetes management and guidelines during Ramadan. J R Soc Med. 2010;
103(4): 139-147.
4. Loke SC, Rahim KF, Kanesvaran R, et al. A prospective cohort study on the effect of various risk factors on hypoglycaemia
in diabetics who fast during Ramadan. Med J Malaysia. 2010; 65(1): 3-6.
2

Section 2

PATHOPHYSIOLOGY OF FASTING DURING RAMADAN

SECTION 2 PATHOPHYSIOLOGY OF FASTING

DURING RAMADAN
An appreciation of the physiology of fasting is essential to the understanding of therapeutic
interventions and the effect of food deprivation in Ramadan. Muslims intentionally abstain from
eating, drinking, and smoking from predawn to sunset. The changes that occur in the body in
response to fasting depend on the length of the continuous fast. The body enters into a fasting
state eight hours or so after the last meal, when the gut finishes absorption of nutrients from
the food.

In the transition from a fed to fasted state (Figure 1):1

i. In the normal fed state, glycogen is the bodys main source of energy.
ii. Secretion of insulin is reduced while counter-regulatory hormones glucagon and
catecholamines are increased.
iii. During a fast, these glycogen stores are utilised first to produce energy. The liver glycogen is
depleted in the first 18 to 24 hours via glycogenolysis.
iv. Later in the fasting state, once glycogen stores are depleted, fat becomes the next source of
energy for the body. Fats are mobilised in the form of triglycerides which further undergo
lipolysis into free fatty acids and glycerol.
v. With prolonged periods of fasting (days to weeks), protein becomes the source of energy and
will be released from the catabolism of muscle.

Gluconeogenesis & ketogenesis

increased glucose uptake

GLUCOSE
LIVER
Glycogen stores
depletion excessive
breakdown

PERIPHERAL
TISSUES
(MUSCLE)
PANCREAS
Insulin secretion
decreased or absent

Figure 1. Pathophysiology of fasting in diabetes.1

4

As the Ramadan fast only extends from dawn till dusk, there is ample opportunity to replenish
energy stores at pre-dawn and dusk meals. This provides a gradual transition from using glucose
to fat as the main source of energy, and prevents the breakdown of muscle for protein.1
After a few days of fast, circulating endorphin levels increase, resulting in improved alertness
and general well-being.2 Balanced food and fluid intake is important between fasts. The renal
homeostasis mechanism maintains the bodys water and salts, such as sodium and potassium. A
balanced diet with adequate quantities of nutrients, salts and water is vital.1

Type 1 diabetes1
In patients with Type 1 diabetes, glucose homeostasis is affected by underlying disease and
by insulin therapy. Glucagon secretion may fail to increase appropriately in response to
hypoglycaemia, and in patients with severe insulin deficiency, a prolonged fast in the absence of
adequate basal insulin can lead to excessive glycogen breakdown and increased gluconeogenesis
and ketogenesis leading to hyperglycaemia and eventual ketoacidosis.

Type 2 diabetes1
Patients with Type 2 diabetes may suffer similar consequences, however ketoacidosis.
is uncommon.
There can be varying changes in body weight among diabetics fasting in Ramadan. The
Epidemiology of Diabetes and Ramadan (EPIDIAR) study showed that majority of patients
had unchanged weight.3 Many patients show no significant change in their glycaemic control
although blood lipid levels have been shown to be reduced.4-7

References
1. Karamat MA, Syed A, Hanif W. Review of diabetes management and guidelines during Ramadan. J R Soc Med. 2010;
103(4): 139-147.
2. Lahdimawan A, Handono K, Indra MR et al. Effect of Ramadan Fasting on Endorphin and Endocannabinoid level in
Serum, PBMC and Macrophage. International Journal of Pharmaceutical Science Invention. 2013; 2(3): 46-54.
3. Salti I, Bnard E, Detournay B, et al. A population-based study of diabetes and its characteristics during the fasting
month of Ramadan in 13 countries: results of the epidemiology of diabetes and Ramadan 1422/2001 (EPIDIAR) study.
Diabetes Care. 2004; 27(10): 2306-2311.
4. Akanji AO, Mojiminiyi OA, Abdella N. Beneficial changes in serum apo A-1 and its ratio to apo B and HDL in stable
hyperlipidaemic subjects after Ramadan fasting in Kuwait. Eur J Clin Nutr. 2000; 54(6): 508-513.
5. Mafauzy M, Mohammed WB, Anum MY, et al. A study of the fasting diabetic patients during the month of Ramadan.
Med J Malaysia. 1990; 45(1): 14-17.
6. Uysal AR, Erdoan MF, Sahin G, et al. Clinical and metabolic effects of fasting in 41 type 2 diabetic patients during
Ramadan. Diabetes Care. 1998; 21(11): 2033-2034.
7. Yarahmadi Sh, Larijani B, Bastanhagh MH, et al. Metabolic and clinical effects of Ramadan fasting in patients with type
II diabetes. J Coll Physicians Surg Pak. 2003; 13(6): 329-332.

Section 3

MEDICAL BENEFITS OF FASTING DURING RAMADAN

SECTION 3 MEDICAL BENEFITS OF

FASTING DURING RAMADAN
Many people observe fasting as a religious obligation and should be aware of the health benefits.
The possible benefits of fasting may include:
Decrease in body weight.
The reduction in body mass index (BMI) may be due to a decrease in the number of meals
(two meals instead of three) that significantly contributes to the reduction of calorie intake.1
Increase in high-density lipoprotein (HDL) cholesterol, with or without any changes in total
cholesterol and triglycerides levels.2
Improvement in glycaemic control in diabetics.3
Decrease in daytime average systolic and diastolic blood pressures in hypertensive patients.4,5
Improvement in immunity by elimination of toxins; reducing insulin-like growth factor 1 (IGF-1)
which allows the regeneration of stem cells in the bone marrow.6
Reduce cardiovascular disease markers such as high sensitive C-reactive protein (hs-CRP) and
plasminogen activator inhibitor type-1 (PAI-1).7

References
1. Mafauzy M, Mohammed WB, Anum MY, et al. A study of the fasting diabetic patients during the month of Ramadan.
Med J Malaysia. 1990; 45(1): 14-17.
2. Benaji B, Mounib N, Roky R, et al. Diabetes and Ramadan: review of the literature. Diabetes Res Clin Pract. 2006; 73(2):
117-125.
3. Chamakhi S, Ftouhi B, Rahmoune NB, et al. Influence of the fast of Ramadan on the balance glycemic to diabetics.
Medicographia. 1991; 13: 27-29.
4. Perk G, Ghanem J, Aamar S, et al. The effect of the fast of Ramadan on ambulatory blood pressure in treated
hypertensives. J Hum Hypertens. 2001; 15(10): 723-725.
5. Akturk IF, Biyik I, Kocas C, et al. PP-014 The effect of Ramadan fasting on blood pressure levels of hypertensive patients
with combination therapy. Int J Cardiol. 2012; 155(Suppl 1): S103.
6. Cheng CW, Adams GB, Perin L, et al. Prolonged fasting reduces IGF-1/PKA to promote hematopoietic-stem-cell-based
regeneration and reverse immunosuppression. Cell Stem Cell. 2014; 14(6): 810-823.
7. Ibrahim O, Kamaruddin N, Wahab N, et al. Ramadan fasting and cardiac biomarkers in patients with multiple
cardiovascular disease risk factors. The Internet Journal of Cardiovascular Research. 2010; 7(2).
8

Section 4

RISKS OF FASTING IN DIABETES DURING RAMADAN

SECTION 4 RISKS OF FASTING IN DIABETES

DURING RAMADAN
Fasting in diabetes during Ramadan may be associated with adverse outcomes in certain
individuals which include hypoglycaemia, hyperglycaemia / ketoacidosis and dehydration.

1. Hypoglycaemia
The effect of fasting during Ramadan on the rates of hypoglycaemia in patients with diabetes is
not known with certainty. However, the Epidemiology of Diabetes and Ramadan (EPIDIAR) study
showed a 4.7 fold increase in hospitalisation due to severe hypoglycaemia in Type 1 diabetes and
7.5 fold in Type 2 diabetes. Severe hypoglycaemia was also more frequent in patients who made
inappropriate changes to their medications dosages and lifestyle.1
A prospective study done locally showed that the rate of hypoglycaemia was 1.6 times higher
during fasting compared to non-fasting periods.2 Diabetics with HbA1c less than 8% and the
elderly have more than twice the risk of developing hypoglycaemia during the fasting month.

2. Hyperglycaemia / ketoacidosis
In EPIDIAR study, there was a five times increase in severe hyperglycaemia requiring hospitalisation
in Type 2 diabetes. In Type 1 diabetes, there were three times increase in the incidence of severe
hyperglycaemia, with or without ketosis.1
Hyperglycaemia may be due to excessive reduction of medication dosages to prevent
hypoglycaemia. Patients who reported an increase in their food and/or sugar intake during nonfasting hours also had significantly higher rates of severe hyperglycaemia.
Patients who are poorly controlled before Ramadan are at an increased risk of diabetic ketoacidosis
(DKA) when they fast. Excessive reduction of insulin dosage is also a contributing factor.

3. Dehydration
Dehydration happens as a result of limitation in fluid intake, especially if the fasting is prolonged
and in those who perform hard physical labour. Osmotic diuresis as a result of hyperglycaemia
further contributes to water and electrolyte depletion.
Orthostatic hypotension may occur leading to syncope, falls, injuries and fractures. Hypercoagulable states in diabetes might be exacerbated, enhancing the risk of thrombosis and stroke.

References
1. Salti I, Bnard E, Detournay B, et al A population-based study of diabetes and its characteristics during the fasting
month of Ramadan in 13 countries: results of the epidemiology of diabetes and Ramadan 1422/2001 (EPIDIAR) study.
Diabetes Care. 2004; 27(10): 2306-2311.
2. Loke SC, Rahim KF, Kanesvaran R, et al. A prospective cohort study on the effect of various risk factors on hypoglycaemia
in diabetics who fast during Ramadan. Med J Malaysia. 2010; 65(1): 3-6.
10

Section 5

PATIENTS WHO ARE AT RISK OF DEVELOPING

COMPLICATIONS DURING FASTING

11

SECTION 5 PATIENTS WHO ARE AT RISK OF

DEVELOPING COMPLICATIONS
DURING FASTING
For diabetic patients, fasting represents an important personal decision that should be made
based on religious recommendation with careful considerations of the associated risks and
possible detrimental effects of fasting. Therefore, diabetic patients should consult their
healthcare providers prior to fasting. Table 1 categorises a diabetic patients risk of fasting.
Table 1. Categories of risk in patients with Type 1 or Type 2 diabetes mellitus who fast during
Ramadan.1

Very high risk

History of severe diabetes complications within 3 months prior to fasting
Severe hypoglycaemia
Ketoacidosis
Hyperosmolar hyperglycaemic coma
Recurrent hypoglycaemia
Hypoglycaemia unawareness
Acute illness
Sustained poor glycaemic control (HbA1c >9%)
Pregnancy
Advanced renal failure / chronic dialysis

12

High risk
Moderate hyperglycaemia (HbA1c 7.59.0%)
Moderate renal failure
Advanced macrovascular complications
Living alone and treated with insulin or sulfonylureas
Patients with co morbid conditions that present additional risk factors
Old age with ill health
Treatment with drugs that may affect mentation

Moderate risk
Well-controlled diabetes treated with short-acting insulin secretagogues

Low risk
Well-controlled diabetes treated with lifestyle therapy, metformin, acarbose,
thiazolidinediones, and/or incretin-based therapies in otherwise healthy patients
Note: This classification is based largely on expert opinion and not on scientific data derived from clinical studies.
Those who fall in the very high and high risk group are advised to abstain from fasting.
This table is a modification of Table 2 from Recommendations for management of diabetes during Ramadan: update 2010 by Al-Arouj
et al. (2010).

13

Fasting in Special Populations with Diabetes

1. Pregnant women
In general, women with diabetes should be strongly advised against fasting during Ramadan.
However, if they insist on fasting, then special attention should be given to their care. Ideally,
patients should be managed in high-risk clinics staffed by an obstetrician, diabetologist, a
nutritionist, and diabetes nurse educators. The management of pregnant patients during
Ramadan is based on an appropriate diet and intensive insulin therapy.1
2. Children and adolescents
Children and adolescents with good glycaemic control who do regular self-monitoring can fast
safely during Ramadan provided that a well structured program of education for both children
and their families is completed prior to Ramadan, and that they receive close follow-up during
the month of Ramadan.2
3. Dialysis patients
Most stable patients on haemodialysis and peritoneal dialysis can fast, provided that they strictly
adhere to their medications and dialysis therapy in addition to the dietary restrictions. These
patients should be followed-up closely to detect any complications and to ensure that adequate
fluid and electrolyte balance are maintained.3,4
4. Elderly patients
Elderly patients are exempted from fasting. Many may wish to observe the fast. Those with
diabetes having any degree of cognitive dysfunction, dehydration, or an increased risk of
thrombosis are advised against fasting.5

References
1. Al-Arouj M, Assaad-Khalil S, Buse J, et al. Recommendations for management of diabetes during Ramadan: update
2010. Diabetes Care. 2010; 33(8): 1895-902.
2. Azad K, Mohsin F, Zargar AH, et al. Fasting guidelines for diabetic children and adolescents. Indian J Endocrinol Metab.
2012; 16(4): 516-518.
3. Al Wakeel J, Mitwalli AH, Alsuwaida A, et al. Recommendations for fasting in Ramadan for patients on peritoneal
dialysis. Perit Dial Int. 2013; 33(1): 86-91.
4. Al Wakeel JS. Kidney function and metabolic profile of chronic kidney disease and hemodialysis patients during
Ramadan fasting. Iran J Kidney Dis. 2014; 8(4): 321-8.
5. Beshyah S, Benbarka M, Sherif I. Practical management of diabetes during Ramadan fast. Libyan J Med. 2007; 2(4):
185-189.
14

Section 6
PREPARATION PRIOR TO RAMADAN

15

SECTION 6 PREPARATION PRIOR TO

RAMADAN
a. PreRamadan medical review
Assessment of the following should be performed 1 2 months before Ramadan:1
Overall wellbeing
Glycaemic control
Blood pressure control
Lipid control
Diabetes-related complications
Diabetes-unrelated comorbidities
Following the assessment, changes in diet and medication regimen may need to be made, so
as to establish a safe and effective anti-diabetic regimen and provide stable glycaemic control
prior to the start of Ramadan fast. The Pre-Ramadan consultation provides an opportunity to
reinforce healthy living advice and encourage patients to stop smoking.2,3
Patients need to be informed regarding the potential risk of fasting. Risk stratification of
diabetic patients who are planning to fast is recommended based on the presence of various
risk factors.
Dose and timing of anti-hypertensive medications may need to be adjusted to prevent
hypotension. Diuretics should be used with caution to avoid volume depletion. Lipid
lowering medications should be continued without the need for dose adjustment, as it is
common practice to have higher intake of foods rich in carbohydrates and saturated fats
during Ramadan.4
It is useful for those with diabetes who intend to fast to start practising fasting in the
months prior to Ramadan. This is in accordance with Islamic teaching and allows for
appropriate dose adjustments of anti-diabetic therapies.

16

b. Patient education
Structured patient education is important to impart the essential elements necessary to
render fasting safer so as to prevent and reduce risks and complications during fasting. The
Ramadan period presents a golden opportunity to empower people with diabetes for better
management of their diabetes, not only in Ramadan but also throughout the year.1,2,5
Educational sessions should be provided by healthcare professionals to people with diabetes
who are intending to fast for Ramadan, preferably several weeks before Ramadan to provide
adequate time for patients, their families and caregivers to prepare for the fasting month.1,2
Patients and care-givers / family members should receive education concerning self-care such
as the following:1,2,6
Risks of fasting
Hypoglycaemia symptoms and signs
Hyperglycaemia symptoms and signs
Dehydration
Blood glucose monitoring during fasting and non-fasting hours
When to stop the fast
Hydration
Meal planning and food choices
Physical activity timing and intensity
Medication administration timing and dosing
Management of Acute complications
Patient education programme may be delivered to people with diabetes either individually or
in a group session at diabetes resource centres and primary health care centres.

17

References
1. Bashir MI, Pathan MF, Raza SA, et al. Role of oral hypoglycemic agents in the management of type 2 diabetes mellitus
during Ramadan. Indian J Endocrinol Metab. 2012; 16(4): 503-507.
2. Benaji B, Mounib N, Roky R, et al. Diabetes and Ramadan: review of the literature. Diabetes Res Clin Pract. 2006; 73(2):
117-125.
3. Karamat MA, Syed A, Hanif W. Review of diabetes management and guidelines during Ramadan. J R Soc Med. 2010;
103(4): 139-147.
4. Al-Arouj M, Assaad-Khalil S, Buse J, et al. Recommendations for management of diabetes during Ramadan: update
2010. Diabetes Care. 2010; 33(8): 1895-902.
5. Hui E, Devendra D. Diabetes and fasting during Ramadan. Diabetes Metab Res Rev. 2010; 26(8): 606-610.
6. Bravis V, Hui E, Salih S, et al. Ramadan Education and Awareness in Diabetes (READ) programme for Muslims with Type
2 diabetes who fast during Ramadan. Diabet Med. 2010; 27(3): 327-331.

18

Section 7

SELF-MONITORING OF BLOOD GLUCOSE DURING Ramadan

19

SECTION 7 SELF-MONITORING OF BLOOD

GLUCOSE DURING Ramadan
Patients with diabetes intending to fast especially those who are on insulin should monitor their
blood glucose levels regularly to detect hypoglycaemia or hyperglycaemia. They should also
conduct self-monitoring of blood glucose (SMBG) if they are not feeling well.1 Finger prick for
SMBG or insulin injection does not constitute breaking of fast.2

When to end a fast

When fasting adversely affect health, patients must always and immediately end their fast. These
conditions are:
Blood glucose < 3.3 mmol/l at anytime during the fast.2
Blood glucose < 3.9 mmol/l in the first few hours of fasting (especially if the patient is taking
sulfonylureas, meglitinides, or insulin).3,4
Blood glucose > 16.7 mmol/l.2
Experience symptoms of hypoglycaemia (patients without SMBG).
Symptoms suggestive of severe dehydration such as syncope and confusion.

Timing and frequency of SMBG based on treatment

1. Oral anti-diabetic (OAD) therapy
To monitor when symptomatic.
2. Insulin therapy
Diabetic patients who are in the moderate to high risk categories (Section 5; Table 1) are
advised to monitor their blood glucose 5 times per day.5
Pre-meal and 2-hour post pre-dawn meal (sahur)
Mid-day
Pre-meal and 2-hour post sunset meal (iftar)
Bedtime
In those who consumes late night meals, bedtime SMBG is recommended. These SMBG readings
can reflect the adequacy of insulin dosing based on type of insulin.

20

Table 2. Timing of SMBG could reflect adequacy of insulin dose.

Time of glucose monitoring

Insulin timing and type

Mid-day

Pre-sahur
Premixed / bolus / basal insulin

Pre-iftar

Pre-sahur
Premixed or basal insulin

2-hour post iftar or bedtime

Pre-iftar
Premixed or bolus insulin

Pre-sahur

Pre-iftar / Pre-bed
Premixed or basal insulin

2 hour post sahur

Pre-sahur
Premixed or bolus insulin

21

References
1. Al-Arouj M, Assaad-Khalil S, Buse J, et al. Recommendations for management of diabetes during Ramadan: update
2010. Diabetes Care. 2010; 33(8): 1895-902.
2. Pathan MF, Sahay RK, Zargar AH, South Asian Consensus Guideline: Use of insulin in diabetes during Ramadan. Indian
J Endocrinol Metab. 2012; 16(4): 499-502.
3. Bravis V, Hui E, Salih S, et al. Ramadan Education and Awareness in Diabetes (READ) programme for Muslims with Type
2 diabetes who fast during Ramadan. Diabet Med. 2010; 27(3): 327-331.
4. Ibrahim MA. Managing diabetes during Ramadan. Diabetes voice. 2007; 52(2): 19-22.
5. Hui E, Bravis V, Hassanein M, et al. Management of people with diabetes wanting to fast during Ramadan. BMJ. 2010;
340:c3053.

22

Section 8

LIFESTYLE AND DIET MANAGEMENT DURING Ramadan

23

SECTION 8 LIFESTYLE AND DIET

MANAGEMENT DURING Ramadan
Meal planning and dietary advice
Appropriate meal planning is important to avoid postprandial hyperglycaemia.
The diet during Ramadan should not differ from a healthy balanced diet. It is encouraged to
consume slow energy-release food (such as wheat, beans and rice) and to distribute calories over
two to three smaller meals during the non-fasting interval.

Adjustment of the diet protocol for Ramadan fasting1

Never skip sahur (dawn meal). Sahur should consist of balanced meal with adequate
carbohydrate taken as late as possible just before Imsak to avoid unnecessary prolonged
fasting.
Do not delay berbuka i.e. the breaking of the fast at sunset, also known as iftar. Limit intake
of high-sugary foods e.g. kuih. However, 1-2 kurma (dates) at start of iftar according to Sunnah
may be taken as part of carbohydrate exchange. Main meal is encouraged after Maghrib
prayers.
Supper after Tarawih can be taken as replacement of pre-bed snack.
Include fruits and vegetables at both sahur and iftar. High fibre carbohydrates are encouraged
at all meals.
Limit fried or fatty foods.
Limit intake of highly salted foods to reduce risk of dehydration.
Sufficient fluid must be taken to replenish fluid loss during the day. Aim for 8 glasses a day.
Choose sugar-free drinks. Drink adequately at sahur.
Dietary indiscretion during the non-fasting period with excessive binging, or compensatory
consumption of carbohydrates especially sweetened and fatty foods contributes to the risk of
hyperglycaemia and weight gain.

24

Figure 2. An illustration of a good buka puasa meal A vs. one that intake should be limited
during buka puasa B .

Physical Activity
Appropriate modification in intensity and timing of physical activity is important to maintain
optimal glycaemic control and optimal weight.
Physical activities and exercise needs to be adjusted during Ramadan. The following are
recommended:2,3
Light and moderate intensity exercise on a regular basis.
Avoid rigorous exercise during fasting time because of risk of hypoglycaemia.
The timing of exercise is preferably 1-2 hours after the break of fast.
Performance of Tarawih night prayers helps to maintain physical activity.

Management of hypoglycaemia during Ramadan

1. Patients need to end their fast if they experience symptoms of hypoglycaemia or have low
blood glucose values (Section 7).
2. Take simple carbohydrates.

25

References
1. Persatuan Dietitian Malaysia. Medical nutrition therapy guidelines for type 2 diabetes mellitus. 2013. Second Edition.
2. Bravis V, Hui E, Salih S, et al. Ramadan Education and Awareness in Diabetes (READ) programme for Muslims with Type
2 diabetes who fast during Ramadan. Diabet Med. 2010; 27(3): 327-331.
3. Karamat MA, Syed A, Hanif W. Review of diabetes management and guidelines during Ramadan. J R Soc Med. 2010;
103(4): 139-147.

26

Section 9

ORAL ANTI-DIABETIC THERAPY DURING Ramadan

27

SECTION 9 ORAL ANTI-DIABETIC THERAPY

DURING Ramadan
The choice of oral anti-diabetic (OAD) therapies should be individualised during fasting.1 Generally,
the insulin secretagogues have higher risk of hypoglycaemia than the insulin sensitizers.2 There is
also probably a need to change the dose and timing of OAD during Ramadan.
In general, OAD therapies that act by increasing peripheral insulin sensitivity may be preferred
due to a low risk of hypoglycaemia. The newer sulphonylureas can be safely used during
Ramadan.3 Dipeptidyl peptidase-4 inhibitors which facilitates insulin secretion in a glucose
dependent manner are safe and have important role in the management of Type 2 diabetes
mellitus during Ramadan fasting in future.4,5
Non-insulin injectables such as glucagon-like peptide-1 receptor agonists do not require dose
adjustments during Ramadan. However, injections may preferably be administered at iftar.

28

Table 3. Adjustments of oral anti-diabetic agents in patients with Type 2 diabetes who are fasting
during Ramadan.6
Regimen

Sunset meal (iftar) Pre-dawn meal (sahur)

-glucosidase inhibitors

No changes

No changes

Twice daily

No changes

No changes

Thrice daily

Two third of dose

One third of dose

Extendedrelease

Full dose

None

Dipeptidyl peptidase-4
inhibitors

No changes

No changes

Meglitinides

No changes

No changes

Biguanides
(Metformin)

Immediaterelease

Sulphonylureas Glibenclamide, No changes

Gliclazide
Gliclazide MR, No changes
Glimepiride

Reduce/omit
Switch dosing to sunset meal

Sodium glucose co-transporter

2 inhibitors*

No changes

Switch dosing to sunset meal

Thiazolidinediones

No changes

None

Modified from Pharmacological approaches to the management of type 2 diabetes in fasting adults during
Ramadan by AlMaatouq (2012).
MR: Modified-release
*Based on expert opinion.

29

References
1. Al-Arouj M, Assaad-Khalil S, Buse J, et al. Recommendations for management of diabetes during Ramadan: update
2010; Diabetes Care. 2010; 33(8): 1895-902.
2. Mafauzy M. Repaglinide versus glibenclamide treatment of Type 2 diabetes during Ramadan fasting. Diabetes Res Clin
Pract. 2002; 58(1): 45-53.
3. Glimepiride in Ramadan (GLIRA) Study Group. The efficacy and safety of glimepiride in the management of type 2
diabetes in Muslim patients during Ramadan. Diabetes Care. 2005; 28(2): 421-422.
4. Al-Arouj M, Hassoun AA, Medlej R, et al. The effect of vildagliptin relative to sulphonylureas in Muslim patients with
type 2 diabetes fasting during Ramadan: the VIRTUE study. Int J Clin Pract. 2013; 67(10): 957-963.
5. Al Sifri S, Basiounny A, Echtay A, et al. The incidence of hypoglycaemia in Muslim patients with type 2 diabetes treated
with sitagliptin or a sulphonylurea during Ramadan: a randomised trial. Int J Clin Pract. 2011; 65(11): 1132-1140.
6. Almaatouq MA. Pharmacological approaches to the management of type 2 diabetes in fasting adults during Ramadan.
Diabetes Metab Syndr Obes. 2012; 5: 109-119.

30

Section 10
INSULIN THERAPY DURING Ramadan

31

SECTION 10 INSULIN THERAPY

DURING Ramadan
In the Epidemiology of Diabetes and Ramadan (EPIDIAR) study, both Type 1 and Type 2 diabetics
on insulin had an increased complication rate of severe hypoglycaemia and hyperglycaemia.1
Few small studies have been conducted among Type 1 diabetics to assess the safety and efficacy
of various insulin type and regimens.2-6 For patients with Type 1 diabetes mellitus who wish to
fast during Ramadan, basal bolus insulin therapy is the preferred regime.
Insulin analogues were shown to be safe with fewer episodes of hypoglycaemia and smaller
post prandial glucose rise after sunset meal (iftar).7 The conventional regular short acting human
insulin and Neutral Protamine Hagedorn (NPH) insulin are more widely used. Insulin glargine can
be given once daily any time after iftar. Insulin levemir and NPH insulin can be given either once
daily at bedtime or divided into twice daily during pre-dawn meal (sahur) and iftar.
Individualised adjustments of insulin dose and timing will need to be implemented when fasting
during Ramadan (Table 4). Self-monitoring of blood glucose (SMBG) will aid in determining the
appropriate insulin dose (Section 7; Table 2). Based on the evaluation of Muslim T2DM patient
observing Ramadan14, the switch from human premix to mid mix analog insulin at iftar resulted
in improvement in glycaemic control without an increase in hypoglycaemia.
Table 4. Insulin adjustments during Ramadan.7-13
Insulin regimen

Type 1 diabetes mellitus

Type 2 diabetes mellitus

Basal insulin
only

Not applicable.

Basal Insulin to be taken at bedtime

or after iftar meals. May need dose
reduction if there is risk of daytime
hypoglycaemia.

Premixed insulin Not applicable.

once daily

Inject usual dose at iftar meals.

Premixed insulin Reverse doses Morning dose

twice daily
given at iftar and evening dose
at sahur.

Reverse doses Morning dose given

at iftar and evening dose at sahur.

Insulin dose at sahur reduced

by 20 50% to prevent daytime
hypoglycaemia.

Insulin dose at sahur reduced

by 20 50% to prevent daytime
hypoglycaemia.
Or
Change to short / rapid acting.*
*Late afternoon hypoglycaemia may occur.

32

Insulin regimen

Type 1 diabetes mellitus

Type 2 diabetes mellitus

Basal bolus
insulin
Basal insulin

Taken at bedtime or any time after iftar meals. May require dose
reduction if there is day time hypoglycaemia.

Bolus/Prandial
insulin

Sahur Usual pre-Ramadan breakfast or lunch dose. May require dose

reduction to avoid daytime hypoglycaemia.
Lunch Omit.
Iftar Usual pre-Ramadan dinner dose. May require dose increment.
*Total insulin requirement for Type 1 diabetics who are on basal bolus insulin regimen while fasting during Ramadan may
require dose reduction by 1530% of their pre-Ramadan dose requirements.

Insulin pump

Basal insulin rate: Unchanged or may require reduction of up to 25%.

Prandial bolus: According to individualised insulin to carbohydrate.
ratio (ICR).

33

References
1. Salti I, Bnard E, Detournay B, et al A population-based study of diabetes and its characteristics during the fasting
month of Ramadan in 13 countries: results of the epidemiology of diabetes and Ramadan 1422/2001 (EPIDIAR) study.
Diabetes Care. 2004; 27(10): 2306-2311.
2. Kobeissy A, Zantout MS, Azar ST. Suggested insulin regimens for patients with type 1 diabetes mellitus who wish to
fast during the month of Ramadan. Clin Ther. 2008; 30(8): 1408-1415.
3. Kassem HS, Zantout MS, Azar ST. Insulin therapy during Ramadan fast for Type 1 diabetes patients. J Endocrinol Invest.
2005; 28(9): 802-805.
4. Kadiri A, Al-Nakhi A, El-Ghazali S, et al. Treatment of type 1 diabetes with insulin lispro during Ramadan. Diabetes
Metab. 2001; 27(4 Pt 1): 482-486.
5. Reiter J, Wexler ID, Shehadeh N, et al. Type 1 diabetes and prolonged fasting. Diabet Med. 2007; 24(4): 436-439.
6. Mucha GT, Merkel S, Thomas W, et al. Fasting and insulin glargine in individuals with type 1 diabetes. Diabetes Care.
2004; 27(5): 1209-1210.
7. Al-Arouj M, Assaad-Khalil S, Buse J, et al. Recommendations for management of diabetes during Ramadan: update
2010. Diabetes Care. 2010; 33(8): 1895-902.
8. Ministry of Health Malaysia. Practical guide to insulin therapy in type 2 diabetes mellitus. 2010.
9. Pathan MF, Sahay RK, Zargar AH, South Asian Consensus Guideline: Use of insulin in diabetes during Ramadan. Indian
J Endocrinol Metab. 2012; 16(4): 499-502.
10. Hui E, Devendra D. Diabetes and fasting during Ramadan. Diabetes Metab Res Rev. 2010; 26(8): 606-610.
11. Bin-Abbas BS. Insulin pump therapy during Ramadan fasting in type 1 diabetic adolescents. Ann Saudi Med. 2008;
28(4): 305-306.
12. Hawli YM, Zantout MS, Azar ST. Adjusting the basal insulin regimen of patients with type 1 diabetes mellitus receiving
insulin pump therapy during the Ramadan fast: A case series in adolescents and adults. Curr Ther Res Clin Exp. 2009;
70(1): 29-34.
13. Benbarka MM, Khalil AB, Beshyah SA, et al. Insulin pump therapy in Moslem patients with type 1 diabetes during
Ramadan fasting: an observational report. Diabetes Technol Ther. 2010; 12(4): 287-290.
14. H
 ui E, Bravis V, Salih S, et al. Comparison of Humalog Mix 50 with human insulin Mix 30 in type 2 diabetes patients
during Ramadan. Int J Clin Pract. 2010; 64(8): 10951099.

34

GLOSSARY OF TERMS

BMI

Body mass index

DKA

Diabetic ketoacidosis

EPIDIAR

HDL

hs-CRP

ICR

IGF-1

Insulin-like growth factor 1

OAD

Oral anti-diabetic

MR

Modified-release

PAI-1

SMBG

Epidemiology of Diabetes and Ramadan

High-density lipoprotein
High-sensitivity C-reactive protein
Insulin to carbohydrate ratio

Plasminogen activator inhibitor type-1

Self-monitoring of blood glucose

ACKNOWLEDGEMENTS
The members of the working committee of this guide would like to express their gratitude and
appreciation to the following for their contributions:
Panel of external reviewers who reviewed the draft.
All those who have contributed directly or indirectly to the development of this guide.

SOURCES OF FUNDING
The development of this guide was supported by an educational grant from:

35