Fasting during Ramadan, Islam's holy month, is a requirement for all healthy adult Muslims. During Ramadan, approximately 40–50 million diabetics worldwide fast. Ramadan is a lunar-based month that lasts between 29 and 30 days. Its timing varies according to the season. Depending on the geographical location and season, the daily fast can last anywhere from a few hours to more than 20 hours. Muslims who fast during Ramadan must refrain from eating, drinking, using oral medications, and smoking from predawn to after sunset; however, there are no food or fluid limitations between sunset and dawn. During this month, most people eat two meals per day, one after sunset, referred to in Arabic as Iftar (breaking of the fast meal), and one before dawn, referred to as Suhur (predawn). Fasting is not intended to cause undue hardship to Muslims.

Fasting during Ramadan may put diabetic patients at risk of a variety of concerns. There are some major risks associated with fasting in patients with diabetes such as hypoglycemia, hyperglycemia, diabetic ketoacidosis, and dehydration. Patients with type 1 diabetes should be strongly advised not to fast in general. Patients with type 1 diabetes who have a history of recurrent hypoglycemia or hypoglycemia unawareness, or who have poorly controlled diabetes, are at a very high risk of developing severe hypoglycemia. On the other hand, in these patients, an excessive reduction in insulin dosage (to prevent hypoglycemia) may put them at risk for hyperglycemia and diabetic ketoacidosis.

Hypo-and hyperglycemia may also occur in patients with type 2 diabetes but generally less frequently and with less severe consequences compared with patients with type 1 diabetes. A patient's decision to fast should be made after extensive discussion with his or her doctor about the risks involved. Patients who insist on fasting should be assessed before Ramadan and receive appropriate education and instructions regarding physical activity, meal planning, glucose monitoring, and medication dosage and timing. The management strategy must be highly personalized. Close monitoring is required to reduce the risk of developing problems.

How to manage diabetic issues during fasting

It is worth emphasizing that fasting for diabetic patients is a significant personal decision that should be made in light of religious exemption guidelines and after careful consideration of the associated risks, as well as extensive discussion with the treating physician.

Several important issues deserve special attention.

Nutrition

The common practice of consuming good amounts of carbohydrates, proteins, and fat-rich foods, especially at the sunset meal, should be avoided. Because of the delay in digestion and absorption, foods containing "complex" carbohydrates may be more appropriate at the predawn meal, while foods containing more simple carbohydrates may be more appropriate at the sunset meal. It is also advised to increase fluid intake during non-fasting hours and to eat the predawn meal as late as possible before the start of the daily fast.

Exercise

Normal levels of physical activity are possible to maintain. Excessive physical activity, on the other hand, may increase the risk of hypoglycemia and should be avoided, especially in the few hours before the sunset meal.

Breaking the fast

All patients should understand that if hypoglycemia (blood glucose of 60 mg/dl [3.3 mmol/l]) occurs, they must always and immediately end their fast because there is no guarantee that their blood glucose will not drop further if they wait or delay treatment. It is also recommended that the fast be broken if blood glucose levels exceed 300 mg/dl (16.7 mmol/l) to prevent hyperglycemia.

Anti-diabetic medications during Fasting

It is extremely important to use anti-diabetic medication to manage diabetes mellitus to avoid its adverse effects. It is recommended to regularly check blood glucose levels. During fasting, patients with diabetes mellitus, if allowed, preferably take the medications after sunset so that they can avoid the religious aspects and can take food till sunrise. Further, some natural antidiabetic herbs can be added to the regular diet to have strict glycemic control. As per Ayurveda and modern science, the below-mentioned herbs have been reported to have positive effects on glycemic levels

Methi (Trigonella faenum gracum) Diabetes patients can benefit from methi by lowering their blood sugar levels. It contains fibre, which aids digestion by slowing digestion and regulating carbohydrate and sugar absorption.

Kalonji (Nigella sativa) can improve hyperglycemia and diabetes control after treatment, with a significant decrease in fasting blood glucose, blood glucose level 2 hours postprandial, glycated hemoglobin, and insulin resistance.

Daruharidra (Berberis aristata) acts as a natural DPP-4 inhibitor to effectively manage diabetes, improves glucose tolerance, and reduces raised blood glucose level effectively along with cardiac protection.

Gudmar (Gymnema Sylvestre) & Vijaysaar (Pterocarpus marsupium) help modulates insulin release, help in the repair & revival of β cells of the pancreas, and increase glucose-mediated insulin release.

Manjistha (Rubia cordifolia) tends to support cardiac protection, generally requires in diabetics, being reported activities which show that it acts as a potent antioxidant, diuretic, calcium channel blocker, antiplatelet, antidiabetic, anti-stress, immune-modulator, etc. which can play an important role to detoxify ischemia-induced free radical generation.

In conclusion, the most important pieces of advice for diabetics to stay protected during the Ramadan and second is to monitor blood glucose more frequently and manage euglycemia by regularly taking the prescribed OHGs and/or polyherbal formulation comprising antidiabetic herbs (BGR-34 and Amree Plus) to effectively manage diabetes.