J Ayub Med Coll Abbottabad 2017;29(1)

ORIGINAL ARTICLE
GLYCAEMIC CONTROL OF TYPE 2 DIABETIC PATIENTS DURING
RAMAZAN FASTING
Uzma Malik, Nasir Mahmood*, Khurshid Ahmed Khan**, Maliha Hameed**, Fawad Ahmed
Randhawa, Sadia Salman, Amna Riaz**, Khadija Waheed, Aqeela Rasheed**
Department of Endocrinology, King Edward Medical University Lahore, *Fatima Jinnah Medical College **Allama Iqbal Medical
College, Lahore-Pakistan

Background: Among five main pillars of Islam Fasting is one of the key elements, all healthy
adult Muslims have to observe fast from dawn till dusk during the holy month of Ramadan.
According to a 2009 demographic study, Islam has 1.57 billion believers, making up 23% of the
world population of 6.8 billion, and is growing by 3% per year. EPIDIAR (epidemiology of
diabetes and Ramadan) study showed that 43% patients with type 1 and 79% patients with type2
diabetes observe fast during the month of Ramadan. Whereas those people who are suffering from
diabetes and are fasting may be at risk of adverse outcomes and the risks may rise with longer
fasting periods. Ideal management of diabetic patients who wish to fast during Ramadan needs to
be done to avoid the complications. The purpose of this study was to observe the effect of fasting
on glycaemic control in type 2 diabetic patients during the month of Ramadan. Methods: This was
an observational cross sectional study; it was conducted at outpatient department Jinnah institute
of diabetes and endocrinology Jinnah hospital Lahore during the month of Ramadan. Patients were
advised to monitor blood sugar levels for two days before and after three meals (lunch, breakfast
and dinner) before Ramadan and then during Ramadan blood sugar levels were monitored for four
days in first Ashra before and two hours after Sehari, for four days at noon during second Ashra
and then for four days pre and two hours after Iftar in last Ashra of Ramadan. Patients were
educated Pre-Ramadan about glucose monitoring and drug dosage adjustments were done along
with dietary counselling. Results: Blood glucose levels two days before and during Ramadan fell
within range of mean glucose level of 150–187 mg/dl showing no extreme fluctuations in blood
glucose levels only one patient reported symptomatic and biochemical hypoglycaemia severe
enough to break the fast at noon. Conclusion: We concluded that in Ramadan fasting, type 2
diabetic patients with proper education, dietary counselling and drug dosage adjustments
glycaemic control can remain in safe acceptable range preventing any life-threatening
complication.
Keywords: Type 2 Diabetes; Fasting; Ramadan; Glycaemic control
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INTRODUCTION during Ramadan,5 lead to the estimation that some

40–50 million people with diabetes worldwide fast
It is estimated that there are 1.1–1.5 billion
during Ramadan. EPIDIAR (epidemiology of
Muslims worldwide, comprising 18–25% of the
diabetes and Ramadan) study also showed that
world population.1 Fasting during Ramadan, a holy
43% patients with type 1 and 79% patients with
month of Islam, is an obligatory duty for all
type2 diabetes observe fast during the month of
healthy adult Muslims.2,3 One of the most
Ramadan.5 People with diabetes that fast are at risk
important components, among five main pillars of
of severe outcomes and the risks may enhance with
Islam is fasting; all healthy adult Muslims have to
longer fasting periods. Proper care of diabetic
observe fast from dawn till dusk during the holy
patients who fast during Ramadan needs to be done
month of Ramadan. According to a 2009
to prevent any complications.6 A better
demographic study, Islam has 1.57 billion
understanding about fasting Ramadan and its risks
believers, making up 23% of the world population
is an important step for all healthcare professionals
of 6.8 billion, and is growing by 3% per year.
dealing Muslim people with diabetes. This
There is 4.6% prevalence of diabetes worldwide.4
necessitates educating patients besides tailoring the
Coupled with the results of the population-based
treatment to meet the needs of diabetic patients to
Epidemiology of Diabetes and Ramadan 7
reduce the possible risks.
1422/2001 (EPIDIAR) study, which showed (in
12, 243 people with diabetes from 13 Islamic Most significant complication related to
countries) that 43% of patients with type 1 diabetes fasting in diabetic patients is Hypoglycaemia,
and 79% of patients with type 2 diabetes fast Hyperglycaemia, Diabetic ketoacidosis,

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Dehydration and thrombosis.7 Professional opinion complications, guidance about management of

recommends that if a patient has made it clear that medication during Ramadan was given. Blood sugar
he or she desire to fast during Ramadan their key levels were checked before and during Ramadan at
physicians and diabetes care experts should specific timings. Before Ramadan a two-day profile of
evaluate their health risk and livelihood to help blood sugar levels was obtained pre and two hour post
them fast as carefully as possibly giving Ramadan breakfast pre and two hour post lunch and pre and two
focused education which include planning for food hour post dinner for baseline readings while during
and advice for diet, Workout blood glucose Ramadan BSL levels were checked before and 2 hours
observation, and recognizing and managing after Sehari for 4 days in 1st 10 days of Ramadan, at
complications. Dose and timing of medicines noon for 4 days in middle 10 days of Ramadan and
should be adjusted on individual basis and strong before and after Iftar in last 10 days of Ramadan. The
follow-up is necessary to decrease the risk for rationale for this protocol was that Ramadan induces
increase in complications.6–8 Recommendations changes in the rhythmic pattern of a number of
and suggestions concerning safe fasting from hormonal variables including cortisol which has an
expert physicians depend on personal experiences unfavourable influence on the glucose tolerance. It has
and evidence based guidelines and evidence based also been argued that a given nutrient ingested at an
guidelines are missing.8 Further research is needed unusual time can induce different metabolic effects.9
to help expand knowledge concerning the risks and Previous research has shown that, unlike in non-fasting
management issues related to fasting in patients periods, cortisol concentrations are biphasic during
with diabetes.7 The purpose of this study is to Ramadan fasting. These researchers reported an increase
access the glycaemic control and any extreme in serum cortisol starting at 1200 h that reached a
blood glucose level variations which may have plateau between 1600 and 2000.10 Estimate of blood
adverse effects during fasting in type 2 diabetic sugar level at fasting state and 2-hour post prandial
patients. The objective of study was to assess the coinciding with normal eating pattern of breakfast, noon
effect of fasting on glycaemic control in type 2 with mid-day timing and pre and post iftar with a fasting
diabetic patients during month of Ramadan. period of 15 hours and post prandial blood glucose level
at iftar. This will give average blood sugar of patients
MATERIAL AND METHODS during 24 hours during fasting period. Any events of
A cross sectional study was conducted at Medical and hypoglycaemia or hyperglycaemia were to be recorded
endocrinology OPD departments Jinnah hospital by the patients during fast. All the information was
Lahore. A non-probability purposive sample was taken. entered in a structured questionnaire. Data was entered
Sample size of 33 was calculated from EPIDAR study and analysed by using SPSS 20.0. Mean and standard
with 95% confidence interval, 10% acceptable error and deviation was calculated for numerical variables like
a standard deviation of .28 for episodes of severe age, Pre-Ramadan blood sugar levels and during
hypoglycaemia among type II diabetic patients during Ramadan blood sugar levels. One way ANOVA with in
fasting. We included patients of either gender between groups was used to see variation between glucose levels
ages of 30–55 years having type II diabetes mellitus of with p<.05 was taken as statistical significant.
more than two years taking oral hypoglycaemic agents
or Insulin and were regularly fasting during past years RESULTS
and have intentions to fast during the holy month. A total of 33 patients with type 2 diabetes who
Patients who at least 20 fasts observed were included in voluntarily fasted during month of Ramadan were
the study. Type 1 diabetic patient and those type 2 recruited for the study. Mean age of patients was
Diabetic patients who want to fast but after medical 51.15±9.36. 42.4% were female and 57.6% were male.
assessment were unfit for fasting, were excluded from 72.7% patients were between 46–70 years of age. Table-
study. Patients having HbA1c more than 10.5 before 1 shows mean BSL pre-breakfast was 159.3485±50.66,
Ramadan, with co morbidities such as advanced micro- mean BSL Post breakfast was 179.95±54.02, mean BSL
vascular complications, chronic liver disease and Pre-lunch was 171.59±50.24, mean BSL Post lunch
advanced chronic kidney disease, stroke, Pregnant and 180.32±43.78, mean BSL Pre-dinner
lactating women were excluded from study. 181.3971±51.80672, mean BSL Post dinner
Fulfilling the inclusion criteria 33 subjects 180.4242±41.02, mean BSL Pre-sehr was
were selected, after approval of hospital ethical 151.41±47.98110, mean BSL Post-sher
committee and taking informed consent from patients. 186.5758±49.98, mean BSL Pre-iftar was
Demographic details (including name, age, gender, 150.37±37.74, mean BSL post-iftar was 187.79±57.16,
contact) were recorded. Patients were given Ramadan mean BSL at noon in Ramadan was 154.56±46.21.
specific education about diet, exercise, blood glucose ANOVA test was used to assess any difference of mean
monitoring and about recognizing and managing between groups was statistically significant. p<.001.

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Table-1: Mean blood sugar levels before and during Ramadan

Descriptive
Blood sugar Levels
95% Confidence Interval for Mean
n Mean Std. Deviation Std. Error Minimum Maximum
Lower Bound Upper Bound
Pre-break 33 159.3485 50.66611 8.81984 141.3831 177.3139 95.00 312.00
Post break 33 179.9545 54.02233 9.40408 160.7991 199.1100 116.00 354.00
Pre lunch 33 171.5909 50.24898 8.74723 153.7734 189.4084 92.50 322.50
Post lunch 32 180.3281 43.78864 7.74081 164.5406 196.1156 105.00 305.00
Pre dinner 34 181.3971 51.80672 8.88478 163.3208 199.4733 106.00 361.00
Post dinner 33 180.4242 41.02707 7.14190 165.8767 194.9718 113.50 290.00
Pre sehr 33 151.4167 47.98110 8.35244 134.4033 168.4300 105.75 309.50
Post sher 33 186.5758 49.98295 8.70091 168.8526 204.2989 126.25 314.00
Pre iftar 33 150.3712 37.74737 6.57097 136.9866 163.7558 109.50 276.25
Post iftar 33 187.7955 57.16938 9.95191 167.5241 208.0668 103.50 365.25
Noon 33 154.5606 46.21705 8.04536 138.1728 170.9485 91.25 299.50
Total 363 171.2541 49.85600 2.61676 166.1082 176.4001 91.25 365.25
ANOVA
Blood sugar Levels
Sum of Squares df Mean Square F Sig.
Between Groups 69436.868 10 6943.687 2.944 .001
Within Groups 830357.751 352 2358.971
Total 899794.619 362

who are able [to fast, but with hardship] - a

ransom [as substitute] of feeding a poor
person [each day]. And whoever volunteers
excess - it is better for him. But to fast is best
for you, if you only knew. [2:184]
The month of Ramadhan [is that] in
which was revealed the Qur'an, a guidance
for the people and clear proofs of guidance
and criterion. So, whoever sights [the new
moon of] the month, let him fast it; and
whoever is ill or on a journey - then an
equal number of other days. Allah intends
Figure-1: Patterns of blood glucose level in for you ease and does not intend for you
relation to various timings during Ramzan fasting hardship and [wants] for you to complete
in type II diabetic patients. the period and to glorify Allah for that [to]
which He has guided you; and perhaps you
DISCUSSION will be grateful. [2:185]
The holy month of Ramadan is one of five main A large epidemiological study of Muslims with
pillars of being a Muslim. Most Muslims are diabetes in 13 Muslim countries (n=12 914)–the
passionate about fasting during this month. Many EPIDIAR study–showed that 43% of patients with
patients with diabetes keep fast during the month of type 1 and 79% of those with type 2 diabetes fasted
Ramadan chronic metabolic disorder of diabetes may during Ramadan. The EPIDIAR study found that the
pose them at risk of complications if pattern of food change in eating patterns during Ramadan increased
and fluid is markedly altered. Quran exempt sick the risk of severe hypoglycemia 4.7-fold (from 3 to
people form fasting if fasting might lead to harmful 14 events per 100 people per month) in type I
consequences Holy Quran ALBAKARAH 183— diabetes and 7.5-fold (from 0.4 to 3 events per 100
185.7 people per month) in type 2 diabetes. It also found a
O you who have believed, decreed upon you fivefold increase in the incidence of severe
is fasting as it was decreed upon those hyperglycemia in patients with type 2 diabetes during
before you that you may become righteous – Ramadan. In another study, Clinical and Metabolic
[2:183] Effects of Fasting in 41 type 2 Diabetic Patients
[Fasting for] a limited number of days. So, during Ramadan number of the symptomatic
whoever among you is ill or on a journey hypoglycemic periods, which were not biochemically
[during them] - then an equal number of verified, increased in eight of the patients (19.5%)
days [are to be made up]. And upon those during Ramadan. None of the patients, however,

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 J Ayub Med Coll Abbottabad 2017;29(1)

experienced severe hypoglycemia or neuroglycopenic glucose control in comparable ranges to Pre-

symptoms.5 Ramadan levels. In a multicentre prospective
Many diabetic patients still insist on and study done in Pakistan of patients with type 1 and
keep fast during the month of Ramadan posing a type 2 diabetes, 33.33% and 48% discontinued
management challenge for themselves as well as for their fast when they felt hypoglycaemic symptoms,
healthcare personals. It is important to know the respectively. None of the patient with type 1, while
potential risks and complications that patient might 18.87% patients with type 2 diabetes discontinued
come across during fasting. Limited prospective and fast on the development of hyperglycaemic
retrospective studies are available on effect of fasting symptoms. Drug dosage and timing were altered in
in type 2 diabetic patients during the month of 80% patients with type 1 and 90.5% patients with
Ramadan. Our study is one of the connecting links type 2 diabetes during Ramadan. Majority of the
between for awareness about glycaemic trends during patients with type 2 diabetes changed from
fasting.4 moderate/severe levels of physical activity before
In this study, we found that the blood sugar Ramadan to light physical activity during Ramadan
levels in fasting type 2 diabetic patients were on (p<0.000).13
higher sides between Ramadan timings. In pre sehr Our study showed that safe fasting
was 105.75–309.50 mg/dl, in post sher 126.25 to without extreme fluctuations of blood sugar levels
314.00 mg/dl, in pre iftar it was 109.50–276.25 is possible in type 2 diabetic patients if they keep
mg/dl, post iftar BSL was103.50–365.25 mg/dl and in touch with their physicians in pre-Ramadan
at noon was 91.25–299.50 mg/dl. In another period for dietary and life style education and their
prospective study in Ramadan this range was 99–199 medication adjustments and also during Ramadan
mg/dl.6 Only one patient during our study had active glucose monitoring and close follow up with
hypoglycaemia enough at midday to break the fast. the concerned physician will help to keep safe fast
Complications regarding the extreme fluctuations of in type 2 diabetic patients. Further prospective
glycaemic control needing hospitalizations were not studies are needed to support our results as well as
reported. One study showed less than 1% to explore new problems faced by type 2 diabetic
hypoglycaemic episodes.11 patients.
In another retrospective study of glycaemic Strengths of our study were actively
trends during Ramadan in fasting diabetic subject’s involving volunteer fasting patients in Pre-Ramadan
frequency of hypo and hyperglycaemia were 21.7% counselling and medication modifications and
and 18.8% respectively whereas 4% patients had providing help services if they needed during the
major hypoglycaemic episodes and 8% had major month of Ramadan which made them fast safely.
hyperglycaemic episodes.9 Limitation of our study was small sample size and
The safe range of glucose levels (less resource limitations.
hypoglycaemia) in our study might be attributable to
patient education about fasting and precautions ACKNOWLEDGEMENTS
advised to be taken about diet drug dosage We acknowledge the support of our supervisor Dr.
adjustment and regular follow-up of Patients during Khurshid Ahmad Khan and staff of Jinnah institute
Ramadan. of diabetes and endocrinology especially Miss.
Study done by Sadiya et al on effect of Maria Sarfaraz, Kamran Albert and Abdul Ghaffar
Ramadan on metabolic markers showed no patients and Dr. Mamoon Akbar Qureshi from community
experience complications or increased symptoms of medicine department for invaluable support and
hypoglycaemia during Ramadan. Total energy help.
consumption remained similar to pre-Ramadan
despite meal frequency decreased (3.2±0.5 vs 2.1±0.4 AUTHORS' CONTRIBUTION
meals/day). Fasting P-glucose (6.3±1.7 vs 6.8±2.0 UM: Main author, Manuscript writing, data collection,
mmol/L, p=0.024).11 Sari et al in his study showed follow up of patients. NM: Data collection, patient follow
body weight, fasting plasma glucose, fructosamine, up, help in stats. KAK: Supervisor. MH: Discussion
HbA1c, total cholesterol was not changed in groups writing. FAR: Discussion writing & manuscript review.
during the study. (p=0.024). Only one hypoglycaemic SS, AR: Data collection. KW: Peer review
event occurred at day 6 of Ramadan in patients in and
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Received: 1 September, 2016 Revised: -- Accepted: 18 December, 2016

Address for Correspondence:
Dr. Uzma Malik, 53-A PIA, Housing Society near Johari Town, Lahore-Pakistan
Cell: +92 323 228 8227
Email: uzma.jahanzaib@hotmail.com

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