TABLE OF CONTENTS

QUALITY IMPROVEMENT COMMITTEE 02

OBJECTIVES 04
SUMMARY OF ALGORITHM 05
SECTION 1 EFFECTS OF FASTING IN PEOPLE 06
WITH DIABETES

SECTION 2 PRE-RAMADHAN ASSESSMENT & 08

EDUCATION

SECTION 3 TREATMENT ADJUSTMENT 13

SECTION 4 THE RAMADHAN NUTRITION PLAN 18

(RNP)

SECTION 5 EXERCISE DURING RAMADAN IN 22

PEOPLE LIVING WITH DIABETES

SECTION 6 DIABETES & RAMADHAN: RELIGIOUS 23

PERSPECTIVE

REFERENCES 24
GLOSSARY 25

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QUALITY IMPROVEMENT COMMITTEE

CHAIRPERSON:

Assoc. Prof. Dr. Lim Lee Ling

Head of Diabetes Care Unit and Senior Consultant Endocrinologist, University of
Malaya Medical Centre

ADVISORS:

Prof. Dr. Shireene Ratna A/P D.B. Vethakkan

Senior Consultant Endocrinologist, University of Malaya Medical Centre

Assoc. Prof. Dr. Jeyakantha A/L Ratnasingam

Head of Endocrine Unit and Senior Consultant Endocrinologist, University of
Malaya Medical Centre

Dr. Sharmila Sunita A/P Paramasivam

Senior Consultant Endocrinologist, University of Malaya Medical Centre

Dr. Lim Quan Hziung

Medical Lecturer and Endocrinology Fellow, University of Malaya Medical Centre

Dr. Nicholas Hee Ken Yoong

Medical Lecturer and Endocrinology Fellow, University of Malaya Medical Centre

Dr Luqman bin Ibrahim

Visiting Consultant Endocrinologist, University of Malaya Medical Centre

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MEMBERS (in Alphabetical Order):

Dr. Khoo Jun Kit

Dr. Krinath A/L Renganadan
Dr. New Ru Peng
Dr. Ooi Ying Guat
Dr. Tharsini A/P Sarvanandan
Dr. Wan Muhammad Jalaluddin bin Wan Mohamed
Dr. Yeoh Kee Ying
Dr. Yew Soo Ying
Medical Officers, University of Malaya Medical Centre

Sr. Azarina Mohd Kenali

Nursing Sister, Diabetes Care Unit, University of Malaya Medical Centre

SN Nor Mala binti Hashim

SN Noor Lizawati binti Rokman
SN Premila A/P Manohara
SN Sharmila binti Abdol Gaffor
SN Suriyani binti Yahaya
Diabetes Educators, Diabetes Care Unit, University Malaya Medical Centre

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OBJECTIVES

The aim of this module is to assist clinicians and allied health personnel in
educating and managing people living with diabetes during the month of
Ramadhan.

With reference to professional guidelines and current evidence, this simplified

module acts as a quick guide towards improving the quality of care and ensuring
safety when managing people with diabetes who wish to fast during Ramadhan in
Malaysia, in an outpatient setting.

This module is meant for all healthcare providers including house officers, medical
officers, specialists, nurses, pharmacists, and dietitians.

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5
 Fasting in people living with diabetes can have varied effects on their physical
well-being. As such, it is imperative for them to understand the potential benefits,
adverse effects, and risks associated with fasting during Ramadhan.

1.1 Potential Benefits and Adverse Physical and Mental Effects of Fasting
during Ramadhan in People with Diabetes

Lifestyle Physical and Mental Potential Adverse

Changes Benefits Effects

▪ Sleep pattern ▪ Sense of fulfillment in ▪ Sleep deprivation and

participating in Ramadhan disruption of
▪ Physical activity
▪ Improved weight and circadian rhythm
▪ Medication BMI leading to increased
▪ Improved self-control and tiredness and
adjustment
ability to resist reduced cognition
temptations
▪ Glucose excursions
▪ Greater spiritual
causing feelings of
benefits
▪ Greater sense of being unwell
community ▪ Fear of diabetes-
▪ Strengthened related complications
relationships ▪ Temporary changes
▪ Reducing potential harmful in weight
vices (e.g., smoking) ▪ Short-term feelings of
stress, anxiety,
irritability, and
agitation

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1.2 Risks of Fasting in People with Diabetes

Risks Explanation / Reason

Hypoglycaemia Especially in patients on insulin

secretagogues (e.g. sulphonylureas) /
insulin
Hyperglycaemia Due to reduced medication dosage and overeating
during non-fasting periods

Diabetic Increased viscosity in the blood due to dehydration with

Ketoacidosis inadequate insulin levels, especially in Type 1 DM

Dehydration Abstinence of fluid intake, also worsened by uncontrolled

hyperglycaemia and glycosuria
Thrombosis Increased viscosity in the blood due to dehydration
(hypercoagulability)

Risk to Pregnancy Risk of adverse effects of hyperglycaemia and

hypoglycaemia to the fetus
Risk of thrombosis due to dehydration
Postural Postural dizziness or syncope due to increased
Hypotension parasympathetic effect

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Pre-Ramadhan assessment and structured education are of utmost importance to
ensure people living with diabetes can fast safely and reduce their risks associated
with fasting. Ideally, it should be done 6-8 weeks prior to Ramadhan. The UMMC
Diabetes Care Unit has offered this structured service since 2022.

2.1 RISK STRATIFICATION

There are 14 key factors in assessing a patient’s risk for undergoing Ramadhan
fasting (Table 2). Risk stratification allows a more individualised approach to
disease management.

An online risk calculator is available from https://daralliancehcp.org/public/risk.

You can also scan this QR code below to access the online calculator:

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Table taken from International Diabetes Federation and DAR International Alliance. Diabetes and
Ramadhan: Practical Guidelines, Brussels, Belgium: International Diabetes Federation, 2021.
www.idf.org/guidelines/diabetes-in-ramadan

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2.2 RISK LEVELS AND RECOMMENDATIONS

MEDICAL
RISK LEVELS RELIGIOUS RECOMMENDATIONS
RECOMMENDATIONS

LOW RISK Fasting is probably safe 1. Fasting is obligatory unless patient is

with: unable to fast due to the physical
(0 - 3 points)
burden of fasting or needing to take
□ Medical evaluation
medications or food or drink during the
□ Medication
fasting hours
adjustment
□ Strict monitoring

MODERATE Fasting safety is 1. Fasting is preferred but

RISK uncertain, requiring : patients may choose not to fast if they
are concerned about their health after
(3.5 - 6 points) □ Medical evaluation
consulting the doctor, considering the
□ Medication
full medical circumstances and patient’s
adjustment
own previous experiences
□ Strict monitoring
2. If the patient wishes to fast,
they must follow medical
recommendations including regular
blood glucose monitoring

HIGH RISK Fasting is probably Advise against fasting

unsafe
(> 6 points)

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2.3 BLOOD GLUCOSE MONITORING

● Patients who were stratified as Low or Moderate risk: blood glucose

monitoring at least 1-2 times per day.
● Patients who were stratified as High Risk: blood glucose monitoring more
than 2 times per day.
● Patients who are on insulin therapy or sulphonylureas: blood glucose
monitoring should be more frequent due to a higher risk of
hypoglycaemia.
● Skin pricking for blood glucose monitoring does not invalidate the
Ramadhan fasting.

Figure taken from International Diabetes Federation and DAR International Alliance. Diabetes and
Ramadhan: Practical Guidelines, Brussels, Belgium: International Diabetes Federation, 2021.
www.idf.org/guidelines/diabetes-in-ramadan

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 2.4 WHEN TO BREAK FAST

2.5 RECOGNITION OF SYMPTOMS OF HYPOGLYCAEMIA AND HYPERGLYCAEMIA

SYMPTOMS OF HYPOGLYCAEMIA SYMPTOMS OF HYPERGLYCAEMIA

▪ Trembling ▪ Extreme thirst

▪ Sweating/ chills ▪ Hunger
▪ Palpitations ▪ Frequent urination
▪ Hunger ▪ Fatigue
▪ Confusion ▪ Confusion
▪ Headache ▪ Nausea/ vomiting
▪ Nightmares ▪ Abdominal pain

2.6 How to break fast?

● Drink plain water first (not sweetened drinks).

● Remember the 15 x 15 rule: to take 15 gram of carbohydrates (e.g., 3 sweets, half
glass of juice, 1 tablespoon honey) and repeat blood glucose 15 minutes later

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Pre-Ramadhan glycaemic control, education, preferences, diet, and lifestyle need
to be considered when formulating individualised treatment plans.

3.1 Medication Adjustment during Ramadhan (Oral/Non-insulin)

Medication Dose modification Pre-dawn Sunset meal

meal (Iftar)
(Sahur)
Biguanides OD
(Metformin) No adjustment
MR/XR
BD

TDS Combine afternoon

dose with evening dose

DPP-4 inhibitors OD/BD No adjustment

Sulphonylureas (SU) OD Reduce dose in
*Switch to newer SU individuals with good
(Gliclazide MR). (Reduce)
glycaemic control
Avoid Glibenclamide BD
(Reduce) (Unchanged)
SGLT2 inhibitors OD No adjustment
(canagliflozin, Take at Iftar
dapagliflozin, *Drink more fluids
empagliflozin)
*No initiation during
Ramadhan

Short-acting insulin Premea Reduce/ Redistribute to

secretagogues l (three- two-meal dosing
(repaglinide, meal according to meal sizes
meglitinides) dosing)

Alpha-glucosidase OD/BD No adjustment

inhibitor (acarbose) TDS May be redistributed to
BD dose

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 Medication Dose modification Pre-dawn Sunset meal
meal (Iftar)
(Sahur)
Thiazolidinediones OD No adjustment
(TZDs)
Glucagon-like Once a No adjustment as long
peptide-1 receptor week as medication has been
agonists dose appropriately
(GLP-1 RA) dose-titrated at least
2-4 weeks prior to
Ramadhan

*No initiation during

Ramadhan

No adjustment as long
as medication has been
OD/BD
appropriately dose-
dose
titrated at least 2-4
weeks prior to
Ramadhan

*No initiation during

Ramadhan

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3.2 Insulin Adjustment for T2DM during Ramadhan

Insulin Regimen Dose Modification

Long/ Intermediate- Once Daily ● Reduce dose by 15-30%

acting (Basal) Insulin ● Take at Iftar
e.g., NPH/ Detemir/
Glargine U100/ Twice Daily ● Take usual morning dose at Iftar
Glargine U300/ ● Reduce evening dose by 50% and
Degludec take at Sahur

Rapid/ Short-acting Prandial/Pre-meal ● Reduce Sahur dose by 25-50%

Insulin ● Omit lunch-time dose
e.g., Lispro, ● Normal dose at iftar
glulisine, aspart, ● Dose titration should be
actrapid performed every 3 days*

Premixed Insulin Once Daily ● Take normal dose at Iftar

e.g., Mixtard,
Novomix, Ryzodeg Twice daily ● Reduce Sahur dose by 25-50%
● Take normal dose at iftar
Three times daily ● Omit afternoon dose
● Adjust Iftar and Sahur dose
● Carry out dose titration every 3
days*

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3.3. Guide to insulin adjustment for T1DM during Ramadhan

Type of Insulin regimen Insulin adjustment Methods of monitoring

CSII / Insulin Pump Basal rate adjustment Continuous glucose monitoring

• 20-40% reduction in dose for
the last 3-4 hours of fasting
• 10-30% increase in dose for
the first few hours after Iftar

Bolus doses
• Same principles as before
Ramadan

MDI (basal bolus) with analogue Basal insulin 7-point glucose monitoring
insulin • 30-40% reduction in dose and
to be taken at Iftar

Rapid-acting Insulin
• 30-50% reduction in dose at
Sahur
• Skip pre-lunch dose • The
dose around Iftar to be adjusted
based on the 2-hour post-Iftar
glucose reading

MDI (Basal bolus) with human NPH insulin 7-point blood glucose
insulin • The usual pre-Ramadan monitoring or 2-3 staggered
morning dose to be taken in the readings throughout the day
evening during Ramadan
• 50% of the pre-Ramadan dose
to be taken at Sahur

Regular insulin
• Dose at evening meal remains
unchanged
• Sahur dose to be 50% of the
pre-Ramadan evening dose
• Skip afternoon dose

Premixed (analogue or human • Shift the usual pre-Ramadan At least 2-3 daily readings and
insulin) morning dose to Iftar whenever any symptoms of
• 50% of the pre-Ramadan hypoglycaemia develop
evening dose at Sahur

Footnotes: CSII, continuous subcutaneous insulin infusion; MDI, multiple daily injection.

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3.3 Additional Notes:
● Risk of hypoglycaemia is higher in individuals with 3 or more drug
combinations, particularly those on both insulin and sulphonylureas.
● Reduction in insulin dose by 25-50% and reduction in sulphonylureas
dose are advised, depending on risk stratification and current level of
glycaemic control.
● Risk of hypoglycaemia is the highest at 3-4 hours before Iftar.
● Individuals on regular human insulin should be switched to analogue
insulin during Ramadhan if possible. Analogue insulin has lower risk of
postprandial hypo- or hyperglycaemia and the administration is more
convenient (can be taken right before meal instead of 30 minutes prior).
● Those with poor glycaemic control (HbA1c > 7.5%) may not require dose
reduction as the medication doses are likely to be insufficient.
● Individuals need to be educated on blood glucose monitoring and self-
titration for insulin doses to ensure safe fasting.
● Administration of insulin via either subcutaneous, intramuscular, or
intravenous route do not invalidate Ramadhan fasting.

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Ramadhan Nutrition Plan (RNP) is designed to individualise Medical Nutrition
Therapy (MNT) for people with diabetes who fast during Ramadhan. It helps to
plan a daily caloric target that helps to maintain or reduce body weight. It also
minimises risks associated with fasting such as hyperglycaemia, hypoglycaemia,
and dehydration.

4.1 Ramadhan Nutrition Plan

● Never skip Sahur. It should be taken as late as possible just before Imsak
and do not delay Iftar to avoid unnecessarily prolonged fasting.
● Consume an adequate amount of protein and fat instead of a carbohydrate-rich
meal at Sahur to minimize postprandial spike of blood glucose and better induce
satiety
● Break fast at Iftar with plenty of water to restore hydration and 1-3 small dates to
raise blood glucose levels.
● Sufficient fluid must be taken to replenish fluid loss during the day. Avoid sugary
drinks, syrups, canned or boxed juices, or fruit juices with added sugar to prevent
sudden spikes in blood glucose.
● Low Glycaemic Index (GI) carbohydrates should comprise 40-50%, lean protein
20-30%, mono or polyunsaturated fats 30-35% and saturated fats comprising <5%
of daily caloric intake.
● Avoid sugar-heavy desserts after Iftar and between meals. A moderate amount of
healthy dessert such as a piece of fruit may be more suitable.
● Supper after Tarawih can be taken as replacement of pre-bed snack.
● Individual choices of food may vary according to preferences but should be
well-balanced and nutritious.
● Refer to the “Ramadhan Nutrition Plate” or the “Malaysian Healthy Plate” (see
Figure 4.4 below) for reference in designing meals.

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4.2 Caloric Targets for Men & Women When Fasting During Ramadhan

4.3 Calorie & Carbohydrate Distribution For RNP

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4.4 Ramadhan Nutrition Plate and Malaysian Healthy Plate

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4.5 Recommended Macronutrient Composition

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5.1 Exercise during Ramadan in People Living with Diabetes

● Avoid excessive physical activity during the day (fasting period) to

minimize the risk of hypoglycaemia and dehydration
● Rigorous exercise during the last hour of fasting should be avoided
● Light exercise can be performed after breaking the fast
● Participating in Tarawih is sunnah and can involve more than 20 rakaat
(iterations in movements in prayers). It can be considered as a mild form
of physical exercise and can be beneficial if they are able to perform it
(precluding factors such as pregnancy, elderly with comorbidities and
limitations in mobility).

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Fasting during the month of Ramadhan is a religious obligation to Muslims. This is
based on a verse in the Holy Quran - Al Baqarah, Verses 183 - 185. However,
based on the same verses too, it has been stated that, those who are ill or unwell
are exempted from fasting to avoid hardship and potential harm. This is based on
the Islamic legal doctrine (Maqasid Shariah) which places preservation of life as
the 1st element in the 5 things to preserve for the benefit of people (Life, Faith,
Intellect, Lineage and Wealth).

Groups That Are Exempted from Fasting

Sick
Traveller (up to 90 KM)
Pregnant, Breastfeeding
Elderly frail person

In the event where fasting may induce harm due to one’s medical condition, they
are encouraged to replace it either by fasting during the subsequent months or to
pay Fidyah, which is equivalent to 650 gram of rice for each fasting day.

Skin pricks for blood glucose monitoring and administration of insulin either via
subcutaneous, intramuscular, or intravenous do not invalidate fasting from a
religious perspective. One of the contemporary Islamic scholars, Sheikh Yusof al -
Qardhawi has mentioned that the usage of intravenous injection with Dextrose
saline/Normal saline do not invalidate fasting. However, in said cases it is
encouraged for them to break their fast and to replace it later (as this usuallly
occurs in those who are unwell and as such are allowed in Islam to apply rukhsah -
leniency).

Patients with diabetes are encouraged to fast a few days before Ramadan. Fasting
for 3 consecutive days can help to detect hypoglycaemia and hyperglycaemia risk
(if any), and allows the patient to adjust their insulin (if any) with the monitoring
and advice from their doctors.

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REFERENCES

1. International Diabetes Federation and DAR International Alliance. Diabetes

and Ramadan: Practical Guidelines, Brussels, Belgium: International Diabetes
Federation, 2021. www.idf.org/guidelines/diabetes-in-ramadan
2. Malaysia Endocrine & Metabolic Society. Practical Guide to Diabetes
Management in Ramadan, 2019. https://mems.my/practical-guide-to-
diabetes-management-in-ramadan/
3. Hassanein M, Bravis V, Hui E, Devendra D. Ramadan-focused education and
awareness in type 2 diabetes. Diabetologia. 2009 Feb;52(2):367-8. doi:
10.1007/s00125-008-1220-8. Epub 2008 Nov 26. PMID: 19034417.
4. Bravis V, Hui E, Salih S, Mehar S, Hassanein M, Devendra D. Ramadan
Education and Awareness in Diabetes (READ) programme for Muslims with
Type 2 diabetes who fast during Ramadan. Diabet Med. 2010 Mar;27(3):327-
31. doi: 10.1111/j.1464-5491.2010.02948.x. PMID: 20536496.
5. Tourkmani AM, Hassali MA, Alharbi TJ, Alkhashan HI, Alobikan AH, Bakhiet
AH, Alqahtani HB, Alrasheedy AA, Alawwad AD, Mishriky AM, Aljadhey H.
Impact of Ramadan focused education program on hypoglycemic risk and
metabolic control for patients with type 2 diabetes. Patient Prefer
Adherence. 2016 Sep 6;10:1709-17. doi: 10.2147/PPA.S113324. PMID:
27660420; PMCID: PMC5019439.
6. National Institute of Diabetes and Digestive and Kidney Disease. August 26
2020. https://www.niddk.nih.gov/health-information/professionals/diabetes-
discoveries-practice/fasting-safely-with-diabetes
7. Malaysian Dietary Guidelines (2010). National Coordinating Committee on
Food and Nutrition. Putrajaya: Ministry of Health Malaysia.

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GLOSSARY

ACRONYM/ TERM EXPLANATION

CHO Carbohydrate

DKA Diabetic ketoacidosis

eGFR Estimated glomerular filtration rate

GI Glycaemic index

GL Glycaemic Load

GTSN Glycaemia-targeted specialised nutrition

HbA1c Glycated haemoglobin, reflects glycaemic control

in past 3 months

Iftar The daily meal consumed during Ramadhan

before sunset

RNP Ramadhan nutrition plan

SFA Saturated Fatty Acid

SMBG Self-monitoring of blood glucose

Sahur / Suhoor The daily meal consumed during Ramadhan

before dawn

Sulfonylureas A class of anti-diabetic drugs that cause release

of insulin through acting on the pancreatic beta
cells. Drugs in this class include glibenclamide,
glimepiride, gliclazide, gliclazide MR

TBSP Tablespoon
- The End -

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UMMC DCU Diabetes Ramadhan Training Module (Version 1, 17 Mar 2022)

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