SINGAPORE - Muslims worldwide observe the ninth month of the Islamic calendar, Ramadan, by abstaining from food and drink during daylight hours.
Those who are diabetic face a number of health risks and need adequate preparation in order to fast safely, said doctors and diabetic care educators.
"The more vital risks are hypoglycaemia (low blood glucose) in view of a long day without food and very high blood glucose levels in the evening and night after breaking fast (Iftar)," said Dr Abdul Shakoor S.K., a consultant at the department of endocrinology at Tan Tock Seng Hospital (TTSH).
If left untreated, hypoglycaemia can lead to serious problems such as a loss of consciousness.
On the other hand, very high blood glucose levels can lead to diabetic ketoacidosis, a serious condition that can be fatal. There is also the risk of dehydration.
ADJUST THE MEDICATION
Before diabetic patients begin to fast during Ramadan, they should discuss it with their doctors to make sure they do it in a safe manner, say medical experts.
Often, some adjustments in medication have to be made.
"Patients who have to take medication three times a day would not need the lunchtime dose during fasting," said Dr Abdul.
"They should take the first dose at Sahur (the meal eaten before fasting commences) and the second dose at Iftar time when they break fast."
That is not all. Their medication and insulin dose should be reduced during Sahur, or it could cause blood glucose levels to drop too much over the course of the day.
Overly high blood glucose levels in the evening and night after breaking fast is a big risk, particularly if a lot of sugar and carbohydrates are eaten, said Dr Abdul.
It is best to eat sensibly and not gorge on food high in sugar and carbohydrates.
"Overeating at Iftar could cause a sudden increase in blood glucose levels," said Ms Noorani Othman, a diabetes nurse educator at TTSH's nursing service.
People who do this without a thought probably have not sought advice from their health-care professionals first, she said.
She said some Muslims also adjust their diabetes medication themselves, based on their experience of the previous Ramadan.
But any change in treatment or health status in the past year could lead to different outcomes, she said.
Low blood glucose levels are usually caused by eating less food than usual, delayed mealtimes or skipping meals, an overdose of diabetes medication and too much or unplanned exercise, she explained.
"Prolonged diarrhoea and vomiting can also lead to hypoglycaemia," she said.
KEEP TRACK OF BLOOD SUGAR
On the other hand, skipping medication, uncontrolled eating, infections and illnesses can increase one's blood glucose levels.
Therefore, it is important for diabetics to have a home glucose testing kit so that they can monitor their blood glucose levels daily, said Dr Stanley Liew, an endocrinologist at Raffles Hospital.
"This is crucial for those who are on high doses of diabetes medication and insulin, as they are prone to low blood sugar levels during prolonged fasting," he added.
Close monitoring means they know when they need to consult a doctor.
As a general rule of thumb, states an educational programme by pharmaceutical firm MSD: "Break your fast if your blood sugar is less than 60mg/dl or greater than 300mg/dl."
MSD, in collaboration with the Diabetic Society of Singapore, recently launched the free "Ramadan, Diabetes and Me" mobile app in Singapore, which is available for Apple iPhone users.
Designed to address challenges faced by people with type 2 diabetes who fast during Ramadan, it has a blood sugar tracker that allows for easy reporting of glucose levels to a health-care practitioner.
But no matter how much help is at hand, some diabetic patients should not fast at all due to the severe health risks. These include the frail and elderly and those with kidney failure, said Dr Abdul.
Can diabetic patients monitor their blood glucose levels during Ramadan?
Muslims are allowed to check their blood glucose levels without having to break their fast, as the amount of blood required is too little to cause harm, such as fainting from too much blood loss.
They can check their blood glucose levels before Sahur, the pre-dawn meal, during midday, just before Iftar or the breaking of fast and at bedtime.
Blood glucose monitoring allows diabetic patients to make adjustments to their food and activities.
Their doctors can also adjust their treatment based on the readings.
What should diabetics take note of when fasting?
1. Limit fried or fatty foods to prevent excessive weight gain, which could lead to a worsening of insulin sensitivity.
2. Eat fibre-rich food, such as fruit, vegetables, beans and wholegrain products before fasting and when breaking fast. This is to maintain satiety and good sugar control.
Examples of high-fibre carbohydrates include brown rice, thosai, chappati, wholemeal or wholegrain breads or biscuits.
3. Do not skip the pre-dawn meal. Have a healthy and balanced meal with enough carbohydrates to avoid fasting for a longer period than necessary.
4. If you break your fast by eating dates, eat just one or two as they are high in sugar.
5. Choose sugar-free drinks and make sure your fluid intake during non-fasting hours is adequate as this helps to prevent dehydration. Eating less food that is high in salt also helps to reduce this risk.
6. See a dietitian if you are unsure of how to plan healthy meals with the right amount of carbohydrates in order to optimise your blood sugar levels during Ramadan.
Ms Melissa Ho, dietitian, department of nutrition & dietetics, Tan Tock Seng Hospital
Should diabetic patients exercise during Ramadan?
Exercise helps to reduce the fat in the body and improve the effects of insulin. There is no reason to stop exercising during Ramadan if the schedule and duration have been carefully considered, especially for those who exercise regularly.
Planning your exercise involves the adjustment of diabetes medication, especially insulin.
As a general rule, you should not do strenuous exercise during the day time (during fasting) to avoid low blood glucose levels and dehydration.
In fact, those who experience frequent hypoglycaemia, particularly in the period leading up to Ramadan, and those who have suffered from severe hypoglycaemia, should not exercise during the fasting period in the day.
Most Muslims do engage in some form of exercise while performing the Tarawih prayers, which involve cycles of standing, bowing, prostrating and sitting, at night during Ramadan.
Ms Noorani Othman, diabetes nurse educator, nursing service, Tan Tock Seng Hospital
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