"O you who believe fasting is prescribed to you as it was prescribed to those before you so that you can learn Taqwa" (Quran 2:183)

Background
All major religions in the world, universally recommend one form of fasting or the other. Fasting during the holy month of Ramadan as recommended by Islam is observed very strictly among all Muslims across the world. This intermittent fasting (referred to as Roza) is the 2nd tenet among the 10 essential tenets referred to as ‘Furoadeen’ according to the Shi’ite school of thought.
According to Islamic scholars, one of the primary objectives of this fast is to teach self-restraint & to remind Muslims of the plight of their brother human beings who are below poverty line and can afford one or two meals per day only.
As per Islamic rules, those observing fast should not only refrain from intake of food and water but also medications from dawn to dusk.
Fiqa-E-Jafferia is more stringent and scholars from this school of thought also restrict injection of medicines, nutritional fluids and drawing of blood for laboratory tests during the period of fasting. Furthermore, not only is the eating pattern greatly altered during the Ramadan period, but the amount and type of food eaten during the night may also be significantly different as compared to that consumed during the rest of the year.
Diabetes is a common disease and it is observed that the number of people affected by diabetes (referred to as sugar complaint in non medical terms) is increasing at an alarming pace world-over; the increase is more predominately reported in developing countries like India. It is surprising that even those people of Indian origin living in other countries like UK, Tanzania, USA etc.
are also more likely to suffer from this ailment than the local population. This disease can affect any individual including Muslim men or women. Basically, there are two types of diabetes- type 1 & type 2 diabetes. Type 2 diabetes is more common & affects mostly overweight people aged above 35 years of age. Type 2 diabetes can be treated with tablets or with insulin, in addition to diet control & regular exercise.
Fasting being a religious obligation to be observed by all Muslims, few Muslims would be willing to refrain from it. This could be due to several reasons like local tradition or a variety of personal reasons. It is seen that even those who have the right to be excused decide to observe the fast. In fact, many people suffering from diabetes also express their desire to fast even though their health does not permit them to do so.
It is prudent to note here that as per Islamic laws, individuals are exempt from Ramadan fasting if they are suffering from an illness that could be adversely affected by fasting. Despite this, people with diabetes may not heed & would not be willing to accept this concession, due to several reasons stated above. If people with diabetes intend to observe fasting during the holy month, they need special attention & care.
Given this background, if a diabetic wishes to take up fasting, there are several questions that could come up in his mind with regards to fasting, such as- who are the people with diabetes who can fast & who should not, if at all one fasts what are the precautions to be taken, what about medications during fasting- what modification is required, are there any special dietary recommendations for people with diabetes who observe fasting etc.
This article is intended at finding answers to these common questions and aims at providing assistance to those people with diabetes who would like to take up fasting during the holy month.

Is fasting beneficial medically?
Currently available literature suggests that there are medical benefits of fasting during Ramadan. However, it is important to emphasize that medical benefits are never the sole reason for taking up fasting, they are secondary in nature. Fasting in general has been used by patients for weight management, to rest the digestive system and for lowering amount of fat in the body. According to medical research from across the globe, fasting during Ramadan can provide the following benefits:
• It can help lower blood sugar levels
• It can lower the amount of cholesterol (fat) in the body
• There is a possibility of lowering blood pressure (BP)
• May help lower weight (1-3 kgs); in diabetics this benefit may or may not be seen.
• Provides psychological benefits such as peace and tranquility for those who fast; Personal hostility reaches minimum levels and the crime rates are reduced.
The above listed benefits of fasting are observed only in those who maintain their appropriate diets.
Furthermore, recitation of the holy Quran is strongly recommended and practiced during this holy month and it has been found that it not only produces tranquility of heart and mind, but also can improve memory. Healthy adult Muslims should not fear becoming weak by fasting, but instead it should improve their health and stamina.

Fasting in diabetics- recommendations
• There are indications that fasting will no way worsen health of an individual, however experts recommend that those who are suffering from severe diseases, whether diabetes or heart disease, kidney stones, etc., are exempt from fasting and should not try to fast • Ramadan fasting is not recommended in people with diabetes with the following features:
- Those with wide fluctuations in blood sugar (glucose) levels
- Those with poor control of diabetes
- Those who do not usually follow medical advise
- Those who have other illnesses in addition to diabetes such as high and uncontrolled blood pressure (BP), heart ailments, infections
- Pregnant women with diabetes
- People with diabetes who have already experienced either high or low sugar more than one time during fasting
• People with well-controlled diabetes can fast but they must do it only under medical supervision. Following your physician’s advice is of utmost importance before & during the fasting period, like always.
• Some experts recommend obligatory fasting in people with diabetes who are overweight & have diabetes that is well under control.
• Those people with type 2 diabetes who are on 1 or 2 tablets for treatment of diabetes can observe Ramadan fasting with appropriate instruction about meals and use of tablets. Such patients have to look out for low sugars and if they develop any problems indicative of low sugar, they have to immediately report to their physician for appropriate changes in medication & diet.

Fasting in diabetics- precautions to take
People with diabetes who observe fasting during the holy month of Ramadan should take the following precautions:
• Patient with the help of his doctor should change his medication to suit his eating patterns (as he skips lunch). A consultation with your doctor 1-2 weeks before Ramadan may be necessary to take a decision on whether to fast or not.
• Overeating at Sehri and Iftar are to be avoided (it is important to remember that Ramadan fasting benefits appear only in patients who maintain their appropriate diets)
• Excess fat & rich foods should be avoided.
• Overexertion or rigorous exercise should be avoided during the period of fasting but it is strongly recommended that those with diabetes continue their usual (routine) physical activity especially during non-fasting periods.
• Regular testing of blood sugars is important before the sunset meal and three hours afterwards and also before Sehri.
• Any signs of low sugar, if at all present even though rare should be recognized early and patient must seek medical advice as early as possible.
• A consultation with the doctor immediately after conclusion of the fasting month is important to adjust medicines and re start therapy like before Ramadan.
To put it very simply a 3D triangle is to be followed- drug adjustment, diet control and daily activity. These three are important steps to ensure successful fasting for those with diabetes.

Summary
Diabetes is commonly encountered in our society & can affect any body including Muslim men & women. Like any other Muslim, people with diabetes also would like to observe fasting during Ramadan. Fasting in Ramadan is safe for the majority of people with diabetes with proper education and diabetic management. Fasting should be observed only under medical supervision. Those with well-controlled diabetes & taking 1 or 2 tablets for diabetes can fast with appropriate changes in tablets & diet.
Monitoring blood sugar levels during Ramadan is important & should be according to medical advice given by the caring physician. Even though several medical benefits of fasting have been known, all people may not benefit from fasting; these benefits are not the only reasons to take up fasting. However those with severe diabetes or heart ailments should refrain from fasting. Islam being a very logical & caring religion exempts people affected with any disease that can be worsened due to fasting from observing the fast. People with diabetes & high blood pressure (BP) should also refrain from fasting.