Can diabetics fast?

Can diabetic patients fast? How should those with diabetes eat during Ramadan? Are there situations where fasting is inadvisable? Spec. Dr. Ferhat Çetin from Türk Diyabet Cemiyeti Kadıköy Hospital and Dietitian Ayşe Üstün answered all these questions and more.

Are there differences in fasting between people with and without diabetes?

Spec. Dr. Ferhat Çetin notes that the general classical guidance for healthy and balanced nutrition for diabetics is to eat 'frequently and in small portions'. "The aim here is to avoid sudden blood sugar fluctuations that could result from uncontrolled eating after prolonged fasting. In daily life, most of us follow a pattern of breakfast in the morning, lunch around midday, and dinner at a reasonable evening hour. This system changes during Ramadan fasting, as food intake is restricted during active daytime hours. Following a long fasting period, the first meal is taken at sunset as iftar, and nutrition ends with a sahur meal consumed near dawn. While these changes in nutrition and sleep patterns have less impact on individuals with healthy sugar metabolism, they can more severely affect people with diabetes, where sugar metabolism is impaired, systemic responses to hunger and satiety are disrupted at various levels, and medications that may have blood-sugar-lowering effects are used." he says.

Approximately one in ten people has diabetes

Çetin states, "Considering that approximately one in ten people has diabetes, it would be incorrect to issue a blanket prohibition or make a universal recommendation. The answer to this question is individual for each diabetic. For someone who requires dialysis three times a week, is 70 years old, and had cardiac bypass surgery last month, fasting could create a life-threatening situation; whereas a diabetic in their thirties who has never experienced hypoglycemia and maintains control through diet and exercise alone could probably fast as comfortably as someone without diabetes." he said. [caption id="attachment_160469" align="aligncenter"] Spec. Dr. Ferhat Çetin[/caption]

Fasting is inadvisable for diabetics with high risk of hypoglycemia

Ferhat Çetin notes that the main concern regarding fasting for diabetics is hypoglycemia in severe cases, a medical emergency that can cause fainting, loss of consciousness, and risk of brain and heart damage. "While hypoglycemia in mild cases can easily be corrected with orally consumed carbohydrates, in severe cases it can lead to poor medical outcomes. Fasting is inadvisable for diabetics with high propensity for hypoglycemia. High-risk and very-high-risk groups regarding hypoglycemia have been defined, and those in these two groups are not recommended to fast. Very-high-risk diabetics include: those who have recently experienced severe hypoglycemia, those treated in hospital for diabetic coma, those experiencing recurrent hypoglycemic episodes, those who do not sense when their blood sugar drops, those acutely suffering from another illness, those with Type 1 diabetes requiring absolute insulin therapy and gestational diabetes, those with kidney failure requiring hemodialysis or those under monitoring for this condition, and those with severe cardiovascular disease. The high-risk group includes: individuals with poorly controlled or uncontrolled blood sugar, Type 2 diabetics using insulin, pregnant women followed on diet alone, those with mild kidney disease, those in professions requiring heavy physical activity, elderly people, those living alone, and those taking neuro-psychiatric medications that can affect consciousness and perception. Those outside these two groups—namely diabetics followed with lifestyle modifications or low-risk blood-sugar-lowering drug classes, with successful blood sugar control and no additional conditions—can fast with careful blood sugar monitoring. Diabetics wishing to fast should consult their doctor about the blood-sugar-lowering risk of their medications." he says.

What methods should a fasting person use to monitor their blood sugar?

Çetin emphasizes that blood sugar measurement from the finger using standard glucose meters can be used safely. "An important point causing confusion on this matter is the religious question of whether blood sugar testing breaks the fast. Religious authorities agree that blood sugar testing does not break the fast. Although blood sugar measurement taken from the finger or vein might in some cases affect ablution, there is no issue regarding fasting. There is no opinion that new-generation continuous glucose monitoring sensors prevent fasting." he continued.

What should a fasting diabetic patient pay attention to regarding food and drink?

Dietitian Ayşe Üstün notes that during Ramadan fasting, since no food or drink is consumed during daytime hours, the periods between meals are considerably longer than outside Ramadan. "The reduction in meal frequency and dehydration can negatively affect diabetes management. Changes in sleep and wakefulness patterns also alter regular eating routines. During Ramadan, some diabetics may prefer to stay awake until sahur. People may have the tendency to eat while awake, which can lead to consuming more calories than needed. If one will not sleep before sahur, it is recommended to choose foods rich in fiber that stabilize blood sugar. Additionally, after iftar, instead of sweets, 1-2 portions of fresh fruit can be consumed as a snack with some nuts, as needed." she says. [caption id="attachment_160470" align="aligncenter"] Dietitian Ayşe Üstün[/caption]

What should be done to maintain fluid balance?

Ayşe Üstün explains that unlike healthy individuals, diabetics may experience more frequent problems regarding fluid and electrolyte balance during Ramadan. "Restriction of daily fluid intake is a condition that negatively affects blood sugar levels. To maintain fluid balance, it is recommended to consume an average of 2 liters of water between iftar and sahur. Furthermore, to prevent fluid loss, it is important to minimize caffeinated and sugary beverages. During Ramadan, weight gain may occur due to inactivity and increased energy intake. Diabetics wishing to increase their physical activity level are advised to increase their activity in hours close to sahur rather than close to iftar, to protect against hypoglycemia and fluid loss. Considering that Taraweeh prayer lasts a long time, it should be evaluated as intense exercise, and diabetics are advised to consume a snack at the beginning or end of the prayer to guard against hypoglycemia." she said.

What are common nutrition mistakes during fasting?

Ayşe Üstün states, "Delaying iftar time extends the existing fasting period further, and consequently when eating begins, the person may not be able to stop. When a diabetic completes their meal quickly, satiety signals have not yet come, so in the following period a desire to continue eating may arise. This can lead to exceeding stomach capacity and consuming more calories than needed. If there is a balanced time between sahur and iftar, the extended fasting period can be somewhat reduced. Sahur meal close to the fasting end time will increase feeling fuller at the start of the day while reducing the intensity of hunger. During Ramadan, consumption of sweets and similar high-sugar foods after iftar may increase. After long hours of fasting, there can be longing for favorite foods. If the amount of these foods is not well controlled, high blood sugar can result. As a nutrition recommendation, beginning the evening meal with a small amount of soup and consuming plenty of vegetables will prevent hunger after iftar. Changes in eating composition between iftar and sahur, and increased energy intake due to fear of hypoglycemia, can lead to weight gain and elevated blood sugar levels. Sudden blood sugar drops during Ramadan may be more frequent, especially in those using insulin and blood-sugar-lowering medications. In order to prevent this situation, excessive food intake conversely causes elevated blood sugar." she concluded.