ADA guideline for diabetes during Ramadan

Most of the diabetic Muslims have strong desire to fast during the month of Ramadan. But many of them can not perform it as there is a risk of an assortment of complications like hypoglycemia, hyperglycemia, diabetic ketoacidosis, dehydration and thrombosis.
A patient's decision to fast should be made after ample discussion with his or her physician concerning the risks involved. Patients who insist on fasting should undergo pre-Ramadan assessment and receive appropriate education and instructions related to physical activity, meal planning, glucose monitoring, and dosage and timing of medications. The management plan must be highly individualised. Close follow-up is essential to reduce the risk for development of complications. American Diabetes Association (ADA) has recommended the following guideline for the proper management of diabetes during Ramadan.
Categories of risks in patients with type 1 or type 2 diabetes who fast during Ramadan
Very high risk

• Severe hypoglycemia within the last 3 months prior to Ramadan
• Patient with a history of recurrent hypoglycemia
• Patients with hypoglycemia unawareness
• Patients with sustained poor glycemic control
• Ketoacidosis within the last 3 months prior to Ramadan
• Type 1 diabetes
• Acute illness
• Hyperosmolar hyperglycemic coma within the previous 3 months
• Patients who perform intense physical labor
• Pregnancy
• Patients on chronic dialysis

High risk

• Patients with moderate hyperglycemia (average blood glucose between 150 and 300 mg/dl
• A1C (7.5-9%)
• Patients with renal insufficiency
• Patients with advanced macrovascular complications
• People living alone that are treated with insulin or sulfonylureas
• Patients living alone
• Patients with comorbid conditions that present additional risk factors
• Old age with ill health
• Drugs that may affect mentation

Moderate risk

• Well-controlled patients treated with short-acting insulin secretagogues such as repaglinide or nateglinide

Low risk

• Well-controlled patients treated with diet alone, metformin, or a thiazolidinedione who are otherwise healthy

Management plan
Individualization: Perhaps the most crucial issue is the realisation that care must be highly individualised and that the management plan will differ for each specific patient.
Frequent monitoring of blood sugar: It is essential that patients have the means to monitor their blood glucose levels multiple times daily. Muslim scholars recommended that blood tests for glucose monitoring and taking insulin do not invalidate the fasting of Ramadan. This is especially critical in patients with type 1 diabetes and in patients with type 2 diabetes who require insulin.
Nutrition: The diet during Ramadan should not differ significantly from a healthy and balanced diet. It should aim at maintaining a constant body mass. The common practice of ingesting large amounts of foods rich in carbohydrate and fat, especially at the sunset meal, should be avoided.
Exercise: Normal levels of physical activity may be maintained. However, excessive physical activity may lead to higher risk of hypoglycemia and should be avoided, particularly during the few hours before the sunset meal.
Breaking the fast: All patients should understand that they must always and immediately end their fast if hypoglycemia (blood glucose of 60 mg/dl [3.3 mmol/l]) occurs, since there is no guarantee that their blood glucose will not drop further if they wait or delay treatment. The fast should also be broken if blood glucose reaches 70 mg/dl (3.9 mmol/l) in the first few hours after the start of the fast, especially if insulin, sulfonylurea drugs, or meglitinide are taken at predawn. Finally, the fast should be broken if blood glucose exceeds 300 mg/dl (16.7 mmol/l).
Pre-Ramadan medical assessment and educational counseling
All patients with diabetes who wish to fast during Ramadan should undergo the necessary preparations to undertake the fast as safely as possible. These include medical assessment and educational counseling.