Ramadan and diabetes: precautions to take

01Diabetes and Ramadan: a specific medical challenge#

The fast of the month of Ramadan, one of the five pillars of Islam, is observed by more than a billion Muslims worldwide, including almost the entire Moroccan population. For people in good health, this profound spiritual practice even shows documented benefits in metabolic and psychological terms. But for people living with diabetes — about 2 million Moroccans — fasting raises specific medical challenges that justify rigorous medical assessment and preparation before and during the holy month.

Daily fasting from dawn to sunset, which can reach 14 to 16 hours during summer in Morocco, profoundly modifies carbohydrate metabolism. During this period, the body progressively depletes its hepatic glycogen reserves and then resorts to gluconeogenesis from lipids and proteins, with production of ketone bodies. In healthy subjects, these metabolic adaptations occur without incident thanks to finely regulated hormonal mechanisms (drop in insulin, rise in glucagon, cortisol and catecholamines). In diabetics, these regulations are disrupted: the pancreas no longer secretes enough insulin or cells resist it, and antidiabetic medications alter hormonal balance. The risk is then twofold: hypoglycaemia from inadequately adapted treatment during the long fasting period, and hyperglycaemia or ketoacidosis during the abrupt food intake at f'tour.

The International Diabetes Centre and the International Diabetes Federation (IDF) in partnership with the Diabetes and Ramadan International Alliance (DAR) published updated recommendations in 2021 which now constitute the international reference, adopted by the Moroccan Society of Endocrinology, Diabetology and Metabolic Diseases (SMEDIAM). These recommendations classify diabetic patients into four risk levels to guide the decision whether or not to fast.

02The 2021 IDF-DAR risk classification#

Risk assessment is the essential step that should guide the personalised decision. It is based on a combination of clinical factors (type of diabetes, control, complications), therapeutic factors (medications used, doses) and contextual factors (age, kidney function, history of severe hypoglycaemia).

Very high risk concerns patients for whom fasting is medically discouraged due to disproportionate risks. These include: patients with type 1 diabetes, particularly with a history of severe hypoglycaemia or ketoacidosis in the preceding 3 months, pregnant or breastfeeding diabetic women, patients with advanced kidney failure (stage 4 or 5, or on dialysis), patients who had a heart attack or stroke in the preceding 3 months, patients with severe diabetic complications (proliferative retinopathy, autonomic neuropathy). For these patients, fasting exposes them to vital risks that formally contraindicate the practice.

High risk concerns patients with type 2 diabetes on insulin therapy, particularly when control is imperfect, elderly and frail patients living alone, those with a history of recurrent moderate hypoglycaemia, or with significant comorbidities (heart failure, chronic liver disease, early cognitive disorders). Fasting is possible but requires enhanced medical follow-up with close consultations before and during Ramadan, multi-daily glycaemic self-monitoring, and clearly defined fast-breaking thresholds.

Moderate risk concerns patients with well-controlled type 2 diabetes on oral antidiabetic agents, with no recent history of hypoglycaemia, no major complications, living in a favourable social environment. Fasting is possible with therapeutic adjustments, particularly to molecules with hypoglycaemic risk (sulfonylureas) and to dosing schedules.

Low risk concerns type 2 diabetic patients on metformin monotherapy or on gliptins, perfectly balanced, without complications, young or in good shape. Fasting is possible with classic follow-up, without major therapeutic adjustment.

This classification should be carried out by the treating physician or endocrinologist during a pre-Ramadan consultation, ideally 6 to 8 weeks before the start of the holy month to allow time for treatment adjustment and patient education.

03The pre-Ramadan consultation, an essential step#

This specific medical consultation, which has become an annual appointment for Moroccan diabetics in the month preceding Ramadan, is probably the single most important measure for a safe Ramadan. It serves several essential objectives.

First, objectively assess the patient's IDF-DAR risk level with a numerical scoring and discuss the decision to fast. This assessment may, in some cases, lead to firmly advising against fasting — which is not a spiritual failure but a correct application of religious teaching that exempts the sick from fasting (Surah Al-Baqarah 2:184). The patient may then compensate by fidya (food donation to a needy person for each day not fasted) or make up the days outside Ramadan if medical improvement allows.

Second, verify recent metabolic balance through HbA1c testing (target below 8% to authorise fasting in most cases), kidney panel (creatinine, eGFR, microalbuminuria), lipid panel, and blood pressure assessment. Recent imbalance, ongoing infection, or metabolic decompensation often requires postponing or avoiding fasting.

Third, adapt the antidiabetic treatment to the specific conditions of Ramadan, by modifying timing, doses or sometimes molecules to optimise glycaemic control during the fasting month. Fourth, educate the patient on intensified glycaemic self-monitoring during Ramadan: 4 to 6 measurements per day for high-risk patients, with clear definition of thresholds requiring immediate fast-breaking. Fifth, provide the patient with adapted equipment: glucose meter, sufficient strips, lancets, sometimes urinary strips for ketonuria in patients at risk of ketoacidosis.

This pre-Ramadan consultation is generally well reimbursed by AMO and constitutes an essential investment for living a serene Ramadan despite diabetes.

04Adapting antidiabetic treatments#

Therapeutic adaptation is probably the most technical and most critical aspect of management. Modifications depend on the pharmacological class used and the patient's overall regimen.

For oral antidiabetic agents

Metformin (Glucophage and generics), first-line treatment for type 2 diabetes, can be maintained with a simple rearrangement of dosing schedules: generally two-thirds of the total dose at f'tour (fast-breaking at sunset) and one-third at suhour (meal taken just before dawn). This molecule presents a very low hypoglycaemic risk and is generally well tolerated during fasting, provided that good hydration is maintained to avoid lactic acidosis.

Hypoglycaemic sulfonylureas (glibenclamide/Daonil, gliclazide/Diamicron, glimepiride/Amarel) present a significant hypoglycaemic risk during fasting, particularly at the end of the day just before f'tour. Several strategies are possible: dose reduction of 25-50%, shifting the entire dose to f'tour, or even temporary replacement during Ramadan with a lower-risk molecule (gliptin). Older-generation sulfonylureas such as glibenclamide should be avoided and replaced by newer generations with a better safety profile.

Gliptins or DPP-4 inhibitors (sitagliptin/Januvia, vildagliptin/Galvus, linagliptin/Trajenta) have an excellent profile during Ramadan: very low hypoglycaemic risk, maintained efficacy, no dose adjustment required. They are the simplest molecules to manage.

Gliflozins or SGLT2 inhibitors (dapagliflozin/Forxiga, empagliflozin/Jardiance) increase the risk of dehydration through their mechanism of action (increased renal elimination of glucose and water). During Ramadan, they require enhanced hydration between f'tour and suhour, and may justify suspension in at-risk patients (elderly subjects, hot climatic conditions, intense physical activity). The rare but serious risk of euglycaemic ketoacidosis must be monitored.

Liraglutide and semaglutide (GLP-1 agonists, Victoza, Ozempic) generally do not require dose adjustment during Ramadan, as their hypoglycaemic effect is glucose-dependent.

For insulin therapy

Insulin adaptation is more delicate and generally requires the expertise of an endocrinologist. The general principles are as follows. Long-acting basal insulin (Lantus, Levemir, Toujeo, Tresiba) should be reduced by 15 to 25% to adapt to reduced caloric intake during fasting, ideally administered in the evening at bedtime after f'tour. Rapid-acting prandial insulins (Novorapid, Humalog, Apidra) are injected just before f'tour, with a dose adapted to meal composition, and at suhour if a significant meal is consumed. Mixed insulins (combinations of rapid and intermediate) are often unsuited to Ramadan and the physician generally suggests a temporary switch to a more flexible and safer basal-bolus regimen. NPH or intermediate insulin is generally contraindicated during Ramadan due to its delayed peak of action which may occur in mid-afternoon, a period at very high hypoglycaemic risk.

05Adapted nutrition during Ramadan#

Nutrition during Ramadan for diabetics must reconcile metabolic constraints with Moroccan cultural traditions, otherwise adherence to advice will be poor. The key is adaptation rather than prohibition.

Suhour, the pre-dawn meal

Suhour is the most important meal for diabetics during Ramadan because it must provide the energy for the fasting hours to come. It should be taken as late as possible before dawn (generally between 4 and 5 a.m. depending on the season) to bring the last food intake closer to the fasting day. Nutritionally, prioritise low-glycaemic-index foods that release their energy progressively: rolled oats, wholemeal bread, whole grains, legumes (lentils, chickpeas), brown or basmati rice, wholewheat semolina. Combine them with quality proteins (eggs, plain yoghurt, fresh cheese, cold chicken breast, fish) which prolong satiety and stabilise blood glucose. Add fibre in the form of raw or cooked vegetables, whole fruits (not juiced), chia or flax seeds. Hydrate generously before the start of fasting — at least 500 mL of water, semi-skimmed milk or unsweetened herbal tea. Avoid traditional Moroccan very sweet pastries at suhour (sellou, sweet briouates, msemen with honey) which cause a major glycaemic peak followed by reactional hypoglycaemia.

F'tour, fast-breaking at sunset

Traditional Moroccan f'tour is rich in fast sugars (dates, juice, sometimes sweetened harira soup, pastries), which poses a specific challenge for diabetics. The rule is to adapt portions rather than eliminate foods. Start with 2 to 3 dates maximum (instead of the traditional 5 to 7) with a large glass of water to break the fast without causing a major glycaemic peak. Dates provide the rapid sugar needed for a controlled glycaemic rise, but in limited quantities. Follow with a bowl of moderately sized harira (the traditional Moroccan harira, rich in legumes, is in fact a good moderate-glycaemic-index dish when not too sweetened). Drink water abundantly rather than sodas, industrial juices or sugary drinks which raise blood glucose rapidly. Avoid excess sweets (chebakia soaked in honey, msemen with honey, Moroccan pastries) which are concentrated in simple sugars — a small piece for pleasure is enough, not a plateful.

Evening meal and between f'tour and suhour

After f'tour, have a complete balanced meal including a portion of protein (chicken, fish, lean meat), abundant vegetables (cooked or as salad), a moderate portion of starches (rice, pasta, wholemeal bread), a fruit for dessert. Limit added fats and frying. Between f'tour and suhour, hydrate regularly to reach a total of 1.5 to 2 litres of water during the night. Light physical activity such as a 30 to 45 minute walk 1 to 2 hours after f'tour is beneficial for glycaemic control. Conversely, avoid intensive sports just before f'tour or in mid fasting day, which expose to risks of hypoglycaemia or dehydration.

06Emergency signals requiring immediate fast-breaking#

Knowing the precise thresholds for breaking the fast is essential for safety. The Quran itself authorises and requires breaking the fast in case of risk to health — this is a medical and religious obligation, not a transgression.

Break the fast immediately in the following situations. Capillary blood glucose below 0.70 g/L (3.9 mmol/L): this is the hypoglycaemia threshold which must be treated without delay by rapid resugaring (3 sugar lumps, 1 glass of juice, 1 date), followed by a slow-release snack (bread, biscuit). Waiting beyond exposes to severe hypoglycaemia which can lead to malaise, loss of consciousness, even seizures. Blood glucose above 3.00 g/L (16.6 mmol/L): severe hyperglycaemia threshold which justifies fast-breaking, hydration, a rapid insulin dose according to the regimen defined by your doctor, and medical follow-up if blood glucose does not decrease. Presence of ketone bodies detected by urinary strip: sign of metabolic decompensation that may evolve into ketoacidosis, an absolute medical emergency.

Clinically, certain symptoms must lead you to break the fast immediately even without an available glucose measurement: profuse cold sweats, tremors, significant dizziness, palpitations, confusion, vision disturbances, great weakness, "head-spinning" sensation, unusual great thirst, very dry mouth, dark urine (signs of dehydration). Do not wait, do not take unnecessary risks: break the fast, treat the problem, contact your doctor or emergency services on 141 if symptoms persist.

Breaking the fast in case of medical emergency does not invalidate your Ramadan: it falls within the religious wisdom that places life preservation above any practice. The broken day can be made up later when your condition allows, or compensated by fidya (donation to a needy person). Several fatwas from the Higher Council of Ulemas of Morocco confirm this interpretation, drawing on classical Islamic jurisprudence.