RAMADAN & DIABETES�SUPPORTING PATIENTS DURING THE HOLY MONTH

2016 © Loblaw Companies Limited or its subsidiaries.  All rights reserved.  Unauthorized duplication or distribution in whole or in part is strictly prohibited. All trademarks are trademarks of their respective owners.

1

Associate Owner SDM 976, 776, 779, 4771

Mohamed Elsabakhawi

2

Learning Objectives

1. Explain what Ramadan is and why Muslims fast during Ramadan
2. Describe the pathophysiology of diabetes and its implications on fasting
3. Explain the role of the pharmacist in providing care to patients during Ramadan
4. List the recommendations relating to fasting as per Diabetes Canada guidelines
5. Describe the management of diabetes medications during Ramadan
6. State key patient counselling points relating to fasting during Ramadan

​

3

What is Ramadan?

• Holiest month of the Islamic Calendar
• The month in which the Holy Quran was revealed to the Prophet Muhammad ﷺ
• 29-30 days long
• Fasting during Ramadan is obligatory on all healthy adults
• Exceptions: those who are sick, elderly, children, pregnant, breastfeeding women, travelers, women who are mensturating

4

Rules of Fasting

• No eating or drinking between dawn to sunset (Fajr to Maghrib)
• No water is consumed during the fast
• Fasting hours for 2026 are around 6am-8pm
• Other prohibitions:
• Smoking
• Intake of anything that replaces the role of food/water (eg: IV fluids, feeding tubes)
• Meals
• Suhoor: Meal consumed prior to dawn (start of fast)
• Iftaar: Meal consumed at sunset (end of fast)
• Allowed to eat/drink between sunset and dawn

​

5

Statistics

• Muslims Living with Diabetes: 148 million (globally)
• This number is expected to increase to 642 million by 2040
• Approximately 116 Million Muslims Living with Diabetes Fast During Ramadan
• 43% of Type 1 Diabetics Fast During Ramadan
• 79% of Type 2 Diabetics Fast During Ramadan
• 30% of diabetics who fast during Ramadan ALSO fast at other times during the year

​

6

Physiology – Healthy Individuals

• After eating:
• ↑ blood glucose
• ↑ insulin secretion
• ↑ storage of glucose as glycogen by liver/muscles
• Glucose levels in normal range
• Not eating (fasting):
• ↓ blood glucose
• ↓ insulin secretion
• ↑ glucagon secretion
• ↑ breakdown of glycogen stores
• Glucose levels in normal range

​

7

Pathophysiology – Fasting Diabetic Patient

• Not eating (during fast):
• ↓ glucose 🡪 Hypoglycemia
• Hormone dysregulation prevents normalization of glucose
• Potential Complication:
• ↓ Glucose stores
• ↑ breakdown of fats
• ↑ ketone production
• ↑ ketoacidosis risk
• Other Complications:
• Dehydration
• Thrombosis (clots)

8

Pharmacist Role

9

Diabetes Canada Risk Stratification

10

Hypoglycemia

• Increased risk during Ramadan (vs pre-Ramadan)
• Type 2 Diabetes: 4.7x higher risk
• Type 1 Diabetes: 7.5x higher risk
• Treatment: 15 grams of simple carbohydrate intake immediately
• Glucose tablets (Dex4)
• 1 tbsp. honey
• 1 tbsp. sugar in water
• 150mL juice or regular soda

​

​

Blood Glucose <4mmol/L

11

Hypoglycemia Management

• Must re-check blood glucose levels 15 minute after treatment
• Driving: Must wait at least 40 minutes AFTER glucose is above 5mmol/L to drive
• Recent increase in car accidents during 4-7pm due to hypoglycemia
• Untreated Hypoglycemia Consequences:
• Loss of consciousness
• Coma
• Brain damage
• Death

Fast MUST be broken if patient experiences hypoglycemia

12

Hyperglycemia

13

Kunafa

14

Baklawa

15

Jalebi

16

Gulab Jamun

17

Hyperglycemia

• Highest risk after Suhoor and Iftaar meals
• Avoid over-eating during the night hours
• Non-adherence to medications may play a role
• Symptomatic hyperglycemia requires referral to the Emergency Department

​

​

Blood Glucose >11mmol/L

18

When to BREAK the fast

​

​

​

19

Blood Glucose Monitoring

• Low/Moderate Risk: 1-2x daily
• High Risk: Multiple times daily
• Tailor SMBG plan for each patient
• Extra tool: Continuous Glucose Monitoring
• Free Style Libre 2
• Dexcom G7
• Be mindful of limitations of CGM technology!

20

Fluid and Diet Management

• Choose low glycemic index, high-fibre foods: beans, barley, brown rice, wheat, oats
• Suhoor: Prefer complex carbohydrate options; long-lasting energy
• Iftaar: Prefer simple (quick) carbohydrate options (fruits, vegetables, whole grains)
• Limit foods high in saturated fats (fried: samosas, bashamil, mahshi)
• Drink of choice: Water or non-sweetened beverages
• Patients should maintain hydration throughout the hours between sunset and dawn
• Avoid sugary desserts (jalebi, gulab jaman) and drinks!
• Best to consult with dietician�before Ramadan

21

DaR Alliance: Ramadan Nutrition Plans

22

Physical Activity

• Maintain normal levels of physical activity (as per pre-Ramadan habits)
• Avoid rigorous exercise
• Avoid strenuous activity during late hours of the fast
• Bonus point for patients: Physical exertions during Taraweeh count as daily exercise
• Studies show night prayers (قِيامُ اللّيل) may improve HbA1c and reduce weight

23

Medication Management

24

Metformin

25

Sulfonylureas (Gliclazide, Glyburide, Glimepiride)

26

Other Medications

• No dose modifications necessary:
• DPP-4 inhibitors
• Januvia (Sitagliptin)
• Trajenta (Linagliptin)
• GLP-1 agonists
• Ozempic (Semaglutide)
• Saxenda (Liraglutide)
• Mounjaro (Tirzepatide)
• As long as the dose has been titrated for at least 6 weeks before Ramadan
• SGLT-2 inhibitors
• Jardiance (Empagliflozin)
• Forxiga (Dapagliflozin)
• Invokana (Canagliflozin)
• Take after Iftaar
• Caution: dehydration risk!
• Insulin: Tailor dosing schedule based on patient’s specific regimen
• Short-acting (Humalog): reduce Suhoor dose by 25-50%, omit lunch dose, take normal dose at Iftaar
• Long-acting (Tresiba): reduce dose by 15-30%, take at Iftaar

​

27

Pharmacist Checklist

28

Resources

​

​

​

29

Scan to Earn UPS Points!

30