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During the holy month of Ramadan, a fast is obligatory for all Muslims who have reached puberty. However, people with chronic diseases like diabetes are often excluded from fasting considering their medical condition.
Despite that, around 43 per cent of type 1 diabetics and 79 per cent of type 2 diabetics worldwide still choose to fast during the month of Ramadan because of their religious views thus, creating a medical challenge for themselves, as well as for medical experts, says a study. 
A recent International Diabetes Federation Atlas Ninth Edition 2019 report has shown that around 112 million people with diabetes may choose to fast during Ramadan, out of 463 million people worldwide. 
The total abstains from drinking, eating and oral medications from dawn to dusk cause harmful consequences to people with diabetes due to their chronic metabolic disorder.
In this article, we will discuss the management of diabetes during the month of Ramadan. Take a look.
What Happens When Diabetics Fast In Ramadan?
When we eat food, insulin is secreted that helps convert the glucose (food breaks into glucose) into energy, along with storing the extra glucose in muscle and liver as glycogen.
When we fast, because of the absence of food (glucose), the level of insulin falls. Simultaneously, a signal is sent to livers and muscles to stimulate the breakdown of stored glycogen and provide energy.
When the fasting exceeds for several hours, as during Ramadan, the glycogen count also gets depleted, followed by low levels of insulin in the body.
In such situations, the release of fatty acid from adipocytes (fat cells) increases. Meaning, instead of glucose, the body starts breaking fatty acids into ketones to fuel the body and provide energy for the proper functioning of vital organs such as muscles, kidney and liver. 
In people with diabetes, both insulin and other counterregulatory hormones are impaired and fasting may aggravate the condition causing severe consequences.
This is because, in some people with diabetes, the production of glucagon (ketones) also fails, and in the absence of both glucose and glucagon, the body gets too low in energy.
Also, sometimes, autonomic neuropathy causes recurrent low insulin levels due to excessive glycogen breakdown and again, energy depletion is caused.
This is the reason why people with diabetes are often not recommended to fast.
COVID-19, Diabetes, Ramadan And Fasting
COVID-19 cases are increasing day by day and a strong immune system is the need of the hour. As we know that in diabetics the immune system is already impaired up to a certain extent, the risk of COVID-19 in those individuals is more compared to people without diabetes.
Ramadan is the holy month in Islam characterised by observing a fast from sunrise to sunset, followed by a meal later. Fasting at such times could be risky because:
- It can lower immunity in the absence of a proper diet or insufficient diet and increase the risk of COVID-19.
- It can worsen diabetes due to decreased food intake and extremely lower glucose levels and cause hypoglycemia.
Therefore, experts suggest focusing more on staying fit and boosting the immune system, rather than fasting during a pandemic and making your condition worse.
Risks Of Fasting In People With Diabetes
Hypoglycemia or low blood glucose due to a reduction in the intake of food.
- Hyperglycemia or high blood glucose due to a sudden increase in insulin levels during the ‘eating hours' of Ramadan. Reduced intake of diabetes medications due to fasting is also the cause of hyperglycemia.
- Dehydration due to reduced intake of fluid, which may get severe during the summer due to excessive sweating. In diabetics who perform vigorous physical activities, the risk of dehydration can increase even more.
- Thrombosis or risk of blood clot due to contraction of blood vessels, linked to dehydration.
- Diabetes ketoacidosis, a severe diabetes complication in which the body starts producing excess blood acids or ketones, especially in people with type 1 diabetes.
Management Of Diabetes During Ramadan
- Know the risks of fasting. This could be done by visiting a medical expert a few weeks prior to the month of Ramadan and understanding whether you are fit to fast for the whole month or not. If the doctor advises not to fast, it must be strictly followed. 
- A proper diabetes management plan should be made before fasting.
- Glucose levels should be monitored many times a day to prevent any complications. This is especially for individuals who are on insulin injections.
- A meal high on carbs and fats should be avoided and instead, complex carbohydrates are suggested.
- Increase the water intake as much as possible.
- Take predawn meal as late as possible before the start of the next day fast.
- Normal physical activities should be maintained and vigorous exercise should be avoided.
- Talk to a medical expert about a change in the medication timings and dosage if you are fasting.
- Break the fast if the blood glucose reaches below 60 mg/dl [3.3 mmol/l during the fasting hours. Also, break the fast if you see the glucose levels reach below 70 mg/dl (3.9 mmol/l after taking an insulin dose or any diabetes medication.
- Avoid fasting on days when you are extremely sick.
- Undergo a medical assessment 1-2 months prior to Ramadhan that focus on empowering patients with diabetes with the knowledge of both, their medical condition and religious views, so that they can make an informed decision and know how to manage their condition while fasting during the month of Ramadan.
Fasting could be good for people with diabetes for 1-2 days a week with proper planning and management. However, fasting for an entire month could be life-threatening. Under the recommendation of a medical expert, some diabetics can however fast, if they fall under the moderate or low risks group.
Diabetics who are in high-risk groups must abstain from fasting and understand the dangers of fasting with their health condition.