Managing diabetes during Ramadan

Paging all diabetics: If you are planning to fast, make sure you are up to date with the latest information and guidelines for a safe Ramadan. Manage your diabetes during Ramadan with medical news you can use.

Where do these recommendations come from?

In 2017 the Diabetes and Ramadan Alliance, AKA Dar Alliance, worked with the International Diabetes Federation to produce practical guidelines for managing diabetes during Ramadan. The Dar Alliance is composed of diabetes organizations based in twelve countries including Algeria, Bahrain, Belgium, Egypt, France, Great Britain, Libya, Pakistan, Senegal, Saudi Arabia, Sudan and the UAE.

Specialists with a thorough grounding in both Ramadan traditions and caring for people living with diabetes have worked together to produce:

Why would diabetes affect fasting for Ramadan?

When you are deciding how to navigate this year’s festivities, it’s important to understand why you need to think carefully about how you approach fasting.

Diabetes is a very serious condition. Too much glucose in your blood can cause long-term damage to your kidneys, eyes, heart and brain among other effects, but too little glucose in your blood can be just as bad. When diabetics fast, they are in danger of developing dehydration, thrombosis, hypoglycaemia, hyperglycemia and diabetic ketosis. These are very significant complications.

Hypoglycemia

When your blood sugar runs very low, your cells don’t have enough energy to keep going. Your body will start to shut down non-essential functions to conserve energy, this will cause some very unpleasant symptoms. These include, fatigue, dizziness, shaking, sweating, confusion, blurry vision, anxiety, hunger, palpitations/racing heart amongst others. If not treated carefully, it can lead to diabetic coma and death.

Hyperglycemia

When your blood sugar stores run low, your body will look for alternative ways to find energy. This can lead to your body releasing too much glucose from your liver stores in one go. If you have type II diabetes, you might be familiar with ‘the dawn phenomenon’. This is a spike in blood sugar levels that happens early in the morning when your body expects you to need a boost on waking. You can trigger hyperglaecimia by deliberately fasting too.

Diabetic ketoacidosis

Diabetics fasting during Ramadan also risk developing diabetic ketoacidosis. When you have run out of glucose stores, your liver will start converting other types of material into energy supplies. When we use our fat stores to make energy, we make waste products called ketones. In normal circumstances a little bit of fat burning makes manageable levels of ketones. When you are getting all of your energy from fat reserves, however, your ketone levels get very high. Ketones are toxic and high levels can make you very sick and even lead to death.

Who should not fast?

I have Type I Diabetes, can I fast?

OK, let’s be frank, if you have type I diabetes, you really should not fast. Managing the careful balance of insulin vs glucose levels is a hassle at the best of times, and fasting will make things more complicated. Especially if your community health system is not prepared. For Muslims in the global North, longer days as we move into spring add an extra wrinkle. In the winter a day might be 8 hours but in the summer in some regions it can be as long as 18 hours. That’s a very long fast for anybody, let alone people who use insulin to manage their blood glucose.

On the other hand, real life often doesn’t match up with the ‘shoulds’. In 2001 an observational study found that in some countries up to around 40% of type I diabetics opted to participate in 15 days of fasting. Diabetes doctors suggest that if you have type I diabetes, even if you are managing it well, you should give fasting a miss. On the other hand, we get it, that’s not always a realistic proposition. If you decide to go ahead, keep your doctor up to date and make sure you have a plan in place in case problems crop up.

There are some situations where you really will put yourself in danger if you fast. The Dar Alliance working with the international Diabetes Federation advises that:

If you are not always on top of managing your blood glucose levels (a pre-Ramadan A1C>9%), you must not fast.

If you are a type I diabetic and pregnant, you must not fast.

If you have had an episode of severe hypoglycaemia or hyperglycemia in the last three months, you must not fast.

If you have had an episode of diabetic ketosis in the last three months, you must not fast.

If you have renal disease or macrovascular complications, you must not fast.

If you are currently sick on top of your diabetes diagnosis, for example you have the flu, COVID-19 or another illness, you must not fast.

If you have uncontrolled epilepsy or cognitive dysfunction, you must not fast.

I have Type II Diabetes, can I fast?

Type II diabetes is the version that comes with age and starts off as insulin resistance. Chances are, if you are searching for information on managing diabetes during Ramadan, this is your first time. The good news is that if you are being conscientious about taking care of your blood glucose levels and keeping your doctor in the loop you should be good to go.

There are some circumstances where you shouldn’t fast as it will increase your chances of becoming unwell:

If your doctor or your family has been nagging you about your numbers, it’s wise to think twice about fasting this year.

If you have type II diabetes and you use insulin, like type I diabetes, it’s probably not a good idea to risk it.

If you have chronic kidney disease or stable macrovascular complications, fasting is not recommended by the experts.

If you are pregnant and managing your type II diabetes without insulin, or you have gestational diabetes, doctors say it’s best for you and your baby to give skip fasting this year.

If you are doing a very active job or working out a lot, physical activity + diabetes + fasting = hypoglycaemia. That’s some bad maths. Maybe change your activity levels or don’t take part in fasting if you can avoid it.

Type II diabetics must not fast if:

If you have had an episode of severe hypoglycaemia or hyperglycemia in the last three months, you must not fast.

If you have had an episode of diabetic ketosis in the last three months, you must not fast.

If you have renal disease or macrovascular complications, you must not fast.

If you are currently sick on top of your diabetes diagnosis, for example you have the flu or another illness, you must not fast.

If you have uncontrolled epilepsy or cognitive dysfunction, you must not fast.

How should I prepare for Ramadan if I have diabetes?

Keep your doctor in the loop

If you have diabetes and you are planning to fast during Ramadan, the most important thing to do is arrange a meet-up with your healthcare provider. Get your glucose levels checked and let your doctor know what’s going on with your health. Your doctor can explain what your specific risks are based on how you are managing your diabetes and together you can decide how you will approach it.

Your physician will come up with a personalized plan to help you keep track of your blood glucose. They will assist you to figure out if you need to change your levels of physical activity, how to know when you need to break the fast and what to do if you experience hypoglycaemia or ketoacidosis, etc. You might need to adjust your medications to account for fasting.

Ideally, you should check in with your healthcare provider a couple of months before Ramadan.

Make yourself a Ramadan Food Plan

The Ramadan Nutrition plan is pretty simple, it’s all about macronutrients. The good news is that a balanced meal that’s safe for people managing their diabetes is also going to work for the rest of the family. Work with your family and community to plan diabetes-friendly meals ahead of time.

Monitor your glucose levels and your weight.

During Ramadan you will need to keep track of your blood glucose to make sure your levels are where they should be. If you are fasting for a full day, your blood sugar levels are going to be less stable than usual. If Ramadan is taking place during late spring in the North, the days will be longer and without careful planning, hypoglycaemia can take you by surprise.

Monitoring your sugar levels will help you to notice patterns and know when you are entering the danger zone. Avoiding hyperglycemia (very high blood glucose levels) after you break your fast is very important as well. When glucose floods your system after a big meal, you will need to be confident that your body can handle this big change to keep your delicate blood vessels healthy.

When it comes to type II diabetes, one of the easiest and most effective ways to fix your problems is weight loss. Whether excess body fat is causative or not, the same behaviours that result in weight loss also turn back the clock on your diabetes.

Counter-intuitively Ramadan is often a pain point for people trying to lose a bit of weight. When you come to a meal very hungry, it’s all too easy to over eat. If you are living with type II diabetes, it’s a good idea to keep track of your weight and monitor any changes. The Dar Alliance suggests that men should be aiming for between 1800 and 2200 calories each day (1800 if you are aiming to lose weight). Women shorter than 4′11″ or 150 cm shouldn’t exceed 1500 calories (1200 for weight loss) and women over 150 cm tall should aim for a range of 1500–2000 calories (1500 for weight loss).

Eat well

Make sure you eat enough. Try to split your daily calories proportionately between Suhoor, Iftar and a couple of snacks. A good division is 30–40% at Suhoor, 40–50% at Iftar and 10–20% reserved for snacks.

Don’t forget to drink

How about starting Iftar with a celebratory glass of water and a couple of dates to relieve your hypoglycaemia? The dates are optional but don’t skip the water. Dehydration is bad news for diabetics. It puts a strain on your kidneys and can precipitate renal failure. Drink as much water or unsweetened beverages as you can, between meals, to keep yourself in good shape. Pass on tea and coffee as they are diuretics. Fruit juice and soft drinks are loaded with sugar and can trigger hyperglycemia.

Use the ‘Ramadan Plate’ method.

Fill between a third and half of your plate with low glycaemic index carbs. Go for whole grains, vegetables and green salads. Skip the white rice, sugar, potatoes and white bread.
Devote around a quarter of your plate to protein. Legumes, nuts, seeds, dairy, fish and poultry are great options for diabetics. If you have kidney disease, you should talk to your doctor about your individual protein needs.
The last part of your plate is for foods containing fats. Keep the saturated fats low, or avoid them altogether. Fish like salmon are great sources of brain-boosting oils while polyunsaturated cooking oils like olive oil are less bad for your heart.

Be selective

Pass on the sugary and fried desserts after Iftar and go for fresh fruit instead.

Choose low glycaemic index carbs to help your body pace itself. Slow-release sugars will help keep your energy levels balanced avoiding hyper and hypoglycaemia.

Reach for proteins or fats first. Protein and fat are more satisfying and more filling than carbohydrates. They also have low glycaemic index for slow and steady energy release and won’t leave you craving more.

Preplan your snacks

If you know you are going to need snacks to stave off hypoglycaemia, plan ahead. Make sure you have a piece of fruit, a handful of nuts or some vegetables packed and ready to grab. Try to keep the portions under 100–200 calories.

Healthy habits for diabetes during Ramadan

So you’ve decided to go ahead, you have your nutrition plan and you’ve tweaked your medication schedule. The last consideration is how to deal with Iftar and Suhoor. When you are hungry and it’s a celebratory meal, or you are anticipating a long day it’s easy to develop some unhealthy habits around eating.

Diabetics need to pay particular attention to how much they eat and when to stay in tip-top health and to make fasting manageable.

Drink water whenever you can. Dehydration is a real danger for people living with diabetes.

Pay attention to portion sizes at Iftar. It’s late and you are hungry. It’s all too easy to put a few extra scoops on your plate. An unusually large meal can send you into hyperglycaemia and over shoot your calorie allowance. If you are trying to control type II diabetes, weight gain is the enemy. Dar Alliance suggest that you try not to exceed 1500 Calories for a single meal to avoid piling on the pounds.

Choose protein or vegetables over refined carbohydrates and avoid sugar. Starchy foods for dinner can cause a blood glucose spike and severe hyperglycemia.

Avoid fried treats. The trans fats in margarine and saturated fats in coconut oil, butter, palm oil, etc might be delicious, but diabetics need to take extra care of the delicate blood vessels.

Give sweet desserts a wide berth. A little of what you fancy can do you good, but not every day, especially between Iftar and Suhoor. You guessed it… hyperglycemia.

Keep snacks small and avoid sugar to prevent the glucose hike and accidentally over eating.

Eat slowly. When you are starving hungry, of course, it’s tempting to eat fast! Take a moment to slow down. It takes around half an hour after eating for your brain to pick up the signals from your stomach that you’ve had enough. Eating fast means you don’t give your body a chance to acknowledge when you have had enough.

Try to have Suhoor as late as possible. If you eat too early, your energy reserves might not last until sunset especially if you live in the Far North. Give yourself a fighting chance to avoid hypoglycaemia in the late afternoon.

Stay active. Nobody’s perfect and if you do find yourself giving in to temptation, keeping up with going for walks, dropping into an exercise class or running after kids can help to mitigate the extra calories.

Finally, make sure you stop in and tell your doctor, health visitor, diabetes nurse or endocrinologist if you are planning to fast. If you become unwell it’s very important that they know what’s going on, and that your family or people around you know who to call.

Sources

Learn more about diabetes during Ramadan:

Fasting at Ramadan and Diabetes – Diabetes Canada. DiabetesCanadaWebsite. Accessed February 25, 2025. https://www.diabetes.ca/research-(1)/our-policy-positions/fasting-at-ramadan-and-diabetes

Dar Alliance. Accessed February 26, 2025. https://daralliance.me/

Bajaj HS, Abouhassan T, Ahsan MR, et al. Diabetes Canada Position Statement for People With Types 1 and 2 Diabetes Who Fast During Ramadan. Canadian Journal of Diabetes. 2019;43(1):3-12. doi:10.1016/j.jcjd.2018.04.007

Al Awadi FF, Echtay A, Al Arouj M, et al. Patterns of Diabetes Care Among People with Type 1 Diabetes During Ramadan: An International Prospective Study (DAR-MENA T1DM). Adv Ther. 2020;37(4):1550-1563. doi:10.1007/s12325-020-01267-4

Hamdy O, Yusof BNM, Reda WH, Slim I, Jamoussi H, Omar M. Chapter 7. The Ramadan Nutrition Plan (RNP) for Patients with Diabetes.

Salti I, Bénard E, Detournay B, et al. A population-based study of diabetes and its characteristics during the fasting month of Ramadan in 13 countries: results of the epidemiology of diabetes and Ramadan 1422/2001 (EPIDIAR) study. Diabetes Care. 2004;27(10):2306-2311. doi:10.2337/diacare.27.10.2306