-Dr. Mohd. Habeeb Haris MD (Consultant Radiologist and Alim graduate)
Diabetes mellitus, often known simply as diabetes, is a group of common endocrine diseases characterised by sustained high blood sugar levels.
Fasting in Ramadhan is one of the five pillars of Islam and is an obligation on all adult Muslims in general, unless they have a valid Shara'i excuse. Fasting can be accompanied by significant changes in: both energy and nutritional intake; in the diet composition; in the working hours; and the usual way of life, which can cause significant metabolic and physiological changes to occur, leading to significant impact on the management and complications of diabetes. The drug doses and timings also would need to be altered.
Diabetic patients are at a high risk for development of a wide range of potential fasting-related complications such as dehydration, hypoglycaemia, hyperglycaemia, and diabetic ketoacidosis (DKA). It should not be overlooked, however, that fasting can be quite beneficial for certain diabetic patients provided that they strictly adhere to the evidence-based guideline and pious physicians’ advice. [Effects of Ramadan Fasting on Social, Psychological and Physical Well Being to Health. International Journal of Contemporary Microbiology. 2015;1(2):25–29]
Current world data show that 4 Muslim-majority countries are ranked within the top 10 diabetes worldwide prevalence. These countries are Pakistan (prevalence 30.8%; rank 1), Kuwait (prevalence 24.9%; rank 2), Egypt (prevalence 20.9%; rank 8), and Qatar (prevalence 19.5%; rank 10).
[Wisevoter, “Diabetes rates by country 2023- wisevoter,” 2023, https://wisevoter.com/country-rankings/diabetes-rates-by-country/]
Since a significant number of Muslims globally have diabetes, many of whom would be fasting in Ramadhan every year, the medical professionals need to be aware of their specific medical needs and the need for providing appropriate medical guidance to such patients. The most important of this is to answer the question - can the diabetic patient safely fast or not?
It's important to correctly guide these patients, based on sound medical evidence and Islamic requirements. If the doctor goes overboard and prevents all diabetics from fasting, he will be answerable to Allah for preventing people from carrying out an important religious obligation. And if he allows even high risk patients to fast due to religious zeal, he will be legally and morally responsible for any complications the patient may suffer due to it.
Ultimately, it's for the treating physician to advise and assist the patient in deciding whether he should fast or not. However, to assist the doctors in making a sound decision, the International Islamic Fiqh Academy has given certain guidelines. But these are from 2009, and the newer treatment protocols and devices like continuous glucose monitoring devices and Insulin pumps might enable a wider range of diabetic patients to fast safely.
The main idea behind these guidelines is to categorise the risk of developing serious adverse effects from fasting.
Guidelines of International Islamic Fiqh Academy:
"The International Islamic Fiqh Academy (IIFA) of the Organization of the Islamic Conference, holding its 19th session (in Sharjah, United Arab Emirates, in April 2009) has stated the following (Resolution No. 183 (9/19) regarding diabetes and fasting:
Medical Classification of Diabetic Patients
First Category
Patients with a very high probability to encounter severe complications from fasting, as medically confirmed. The sickness state of a patient of this category falls under one or more of the following cases:
• Patients who face severe hypoglycaemia during the three months preceding the month of Ramaḍān.
• Patients who face repetitive ups and downs in the ratio of blood sugar.
• Patients who encounter the problem of hypoglycaemia unawareness (loss of symptoms of hypoglycaemia), a state which occurs in some diabetic patients, especially those who are classifiable under type I who face repetitive hypoglycemias for long periods.
• Patients who are known for facing difficulty in controlling diabetes for long periods.
• Cases of “Diabetic Ketoacidosis” complication or (Diabetic Coma) complication.
• Patients of diabetes type I.
• Patients who suffer from other severe diseases that accompany diabetes.
• Diabetic patients who have to do work that require hard physical effort.
• Diabetic patients who undergo dialysis.
• Diabetes during pregnancy.
Second Category
This category includes patients who have a relatively high probability of encountering complications on fasting according to the most-likely opinion of physicians. The sickness status of these patients falls under one or more of the following cases:
Those who suffer high levels of blood sugar as when the level of glycated hemoglobin (HbA1c) exceeds 10%.
Those who suffer renal insufficiency.
Those who suffer large artery diseases (such as cardiovascular diseases).
Those who live alone and receive medication through injection of insulin or by sugar control medicines, which reduce sugar through stimulation of the insulin producing cells in the pancreas.
Those who suffer other diseases, making them vulnerable to additional risks.
Old patients who suffer other diseases.
Patients who receive medical treatments that affect the brain.
Shariah Rulings regarding Patients in Categories I and II
Cases of these two categories are based on certainty or “high probability” that fasting will cause grave harm to them, as per the judgement of specialised and trustworthy physicians. Therefore, a patient who faces any of the cases cited above for identification of patients in these two categories should not fast. It is not permissible for him to fast in order to avoid inflicting harm upon himself. Allāh the Almighty said, «And make not your own hands contribute to your destruction,» (Al-Baqarah, 195) and He سبحانه وتعالى also said, «Nor kill (or destroy) yourselves for verily Allāh hath been to you Most Merciful.» (Al-Nisāʾ, 29) The treating physicians should explain to patients of these two categories how fasting is risky for them and enlighten them about the high probability that they may face complications which could – most likely – be serious to their health or lives. Physicians should also adopt all possible suitable medical procedures, which could enable the patient to fast without facing harm.
Rulings that relate to non-fasting in Ramadan for sickness excuse shall apply to patients in categories I and II in compliance with the directives of Allāh the Almighty Who said, «But if any of you is ill, or on a journey, the prescribed number (should be made up) from days later and for those who can do it (With hardship), is a ransom, the feeding of one that is indigent.» (Al-Baqarah, 184)
If the doctor (after a thorough medical assessment) warns the patient that there is a high or very high risk of serious complications, then the patient would be sinful for fasting against such advise, but his fasting is valid.
Third Category
These are patients who have the medium probability of encountering complications from fasting. This category includes diabetic patients whose cases are stable and well controlled through suitable medicines that reduce sugar by stimulating the insulin producing cells in the pancreas.
Fourth Category
Patients who have low probability to encounter complications from fasting. This category includes diabetic patients whose cases are stable and well-controlled through diet only or by using medicines that reduce sugar by increasing the efficacy of the insulin in the body without stimulating the insulin-producing cells in the pancreas.
Shariah Rulings Regarding Patients in Categories III and IV
Leaving the Fast during the month of Ramaḍān is not allowed for patients in these two categories since medical findings do not indicate harmful complications that could affect their health or lives. Contrarily, some of these patients could even benefit from fasting. So, they should fast.
Physicians have to stick to these rulings and decide suitable treatment for each case separately.
Recommendations
1. Physicians are required to have a suitable degree of knowledge about Shariah rulings relating to this subject. This necessitates the preparation of such material by relevant bodies and disseminating it among those who need it.
2. Fiqh scholars and Islamic preachers are requested to advise fatwa seekers to consult physicians who know medical and religious dimensions of fasting and who fear Allah the Almighty in providing advice on a case by case basis.
3. Due to the severity and seriousness of dangers that could originate from complications of diabetes in case of fasting, and which could badly affect the health and lives of diabetic patients, guidance and information should be provided through all possible means, including sermons at mosques and through mass media, in order to enlighten patients about the rulings above; raising awareness about the disease and how it can be dealt with is essential to mitigate its effects and make it easy to accept Shariah rulings and medical advice pertaining to it.
4. IOMS, in cooperation with the Academy, should assume the task of preparing an information booklet on this subject in Arabic and other languages (spoken by Muslims) and work for its dissemination among physicians and Fiqh scholars, and make it available online for patients to benefit thereof.
5. Calling upon ministries of health in Muslim countries to launch national programs in areas of prevention, medical treatment, medication and awareness about diabetes and their Shariah rulings." [End of quote from IIFA]
Conclusion:
The treating physicians should keep all these factors in mind and decide for themselves how much to rely on this risk categorisation while advising their patients.
Guidelines of International Islamic Fiqh Academy:
"The International Islamic Fiqh Academy (IIFA) of the Organization of the Islamic Conference, holding its 19th session (in Sharjah, United Arab Emirates, in April 2009) has stated the following (Resolution No. 183 (9/19) regarding diabetes and fasting:
Medical Classification of Diabetic Patients
First Category
Patients with a very high probability to encounter severe complications from fasting, as medically confirmed. The sickness state of a patient of this category falls under one or more of the following cases:
• Patients who face severe hypoglycaemia during the three months preceding the month of Ramaḍān.
• Patients who face repetitive ups and downs in the ratio of blood sugar.
• Patients who encounter the problem of hypoglycaemia unawareness (loss of symptoms of hypoglycaemia), a state which occurs in some diabetic patients, especially those who are classifiable under type I who face repetitive hypoglycemias for long periods.
• Patients who are known for facing difficulty in controlling diabetes for long periods.
• Cases of “Diabetic Ketoacidosis” complication or (Diabetic Coma) complication.
• Patients of diabetes type I.
• Patients who suffer from other severe diseases that accompany diabetes.
• Diabetic patients who have to do work that require hard physical effort.
• Diabetic patients who undergo dialysis.
• Diabetes during pregnancy.
Second Category
This category includes patients who have a relatively high probability of encountering complications on fasting according to the most-likely opinion of physicians. The sickness status of these patients falls under one or more of the following cases:
Those who suffer high levels of blood sugar as when the level of glycated hemoglobin (HbA1c) exceeds 10%.
Those who suffer renal insufficiency.
Those who suffer large artery diseases (such as cardiovascular diseases).
Those who live alone and receive medication through injection of insulin or by sugar control medicines, which reduce sugar through stimulation of the insulin producing cells in the pancreas.
Those who suffer other diseases, making them vulnerable to additional risks.
Old patients who suffer other diseases.
Patients who receive medical treatments that affect the brain.
Shariah Rulings regarding Patients in Categories I and II
Cases of these two categories are based on certainty or “high probability” that fasting will cause grave harm to them, as per the judgement of specialised and trustworthy physicians. Therefore, a patient who faces any of the cases cited above for identification of patients in these two categories should not fast. It is not permissible for him to fast in order to avoid inflicting harm upon himself. Allāh the Almighty said, «And make not your own hands contribute to your destruction,» (Al-Baqarah, 195) and He سبحانه وتعالى also said, «Nor kill (or destroy) yourselves for verily Allāh hath been to you Most Merciful.» (Al-Nisāʾ, 29) The treating physicians should explain to patients of these two categories how fasting is risky for them and enlighten them about the high probability that they may face complications which could – most likely – be serious to their health or lives. Physicians should also adopt all possible suitable medical procedures, which could enable the patient to fast without facing harm.
Rulings that relate to non-fasting in Ramadan for sickness excuse shall apply to patients in categories I and II in compliance with the directives of Allāh the Almighty Who said, «But if any of you is ill, or on a journey, the prescribed number (should be made up) from days later and for those who can do it (With hardship), is a ransom, the feeding of one that is indigent.» (Al-Baqarah, 184)
If the doctor (after a thorough medical assessment) warns the patient that there is a high or very high risk of serious complications, then the patient would be sinful for fasting against such advise, but his fasting is valid.
Third Category
These are patients who have the medium probability of encountering complications from fasting. This category includes diabetic patients whose cases are stable and well controlled through suitable medicines that reduce sugar by stimulating the insulin producing cells in the pancreas.
Fourth Category
Patients who have low probability to encounter complications from fasting. This category includes diabetic patients whose cases are stable and well-controlled through diet only or by using medicines that reduce sugar by increasing the efficacy of the insulin in the body without stimulating the insulin-producing cells in the pancreas.
Shariah Rulings Regarding Patients in Categories III and IV
Leaving the Fast during the month of Ramaḍān is not allowed for patients in these two categories since medical findings do not indicate harmful complications that could affect their health or lives. Contrarily, some of these patients could even benefit from fasting. So, they should fast.
Physicians have to stick to these rulings and decide suitable treatment for each case separately.
Recommendations
1. Physicians are required to have a suitable degree of knowledge about Shariah rulings relating to this subject. This necessitates the preparation of such material by relevant bodies and disseminating it among those who need it.
2. Fiqh scholars and Islamic preachers are requested to advise fatwa seekers to consult physicians who know medical and religious dimensions of fasting and who fear Allah the Almighty in providing advice on a case by case basis.
3. Due to the severity and seriousness of dangers that could originate from complications of diabetes in case of fasting, and which could badly affect the health and lives of diabetic patients, guidance and information should be provided through all possible means, including sermons at mosques and through mass media, in order to enlighten patients about the rulings above; raising awareness about the disease and how it can be dealt with is essential to mitigate its effects and make it easy to accept Shariah rulings and medical advice pertaining to it.
4. IOMS, in cooperation with the Academy, should assume the task of preparing an information booklet on this subject in Arabic and other languages (spoken by Muslims) and work for its dissemination among physicians and Fiqh scholars, and make it available online for patients to benefit thereof.
5. Calling upon ministries of health in Muslim countries to launch national programs in areas of prevention, medical treatment, medication and awareness about diabetes and their Shariah rulings." [End of quote from IIFA]
Conclusion:
So, before deciding whether to fast or not, the patient should consult a knowledgeable and God-fearing doctor and also consult a good Islamic scholar, so that a correct decision can be taken from both medical and Islamic perspective.
Summary chart from Shaikh Dr. Rafaqat Rasheed's lecture on Fiqh of fasting.
Trial Fasting when in doubt:
When there is some doubt on the ability (and safety) of the patient to fast, Shaikh Dr. Rafaqat Rasheed (General Practitioner and Islamic scholar from UK) suggests trial fasting for diabetics and patients of other chronic diseases before the month of Ramadhan (preferably in Shaban) so that they can get an idea if they can safely fast or not.
Fiqh Ruling (From 'Islamic guidelines on contemporary medical issues' by Mufti Abu Bakar Qasmi):
Trial Fasting when in doubt:
When there is some doubt on the ability (and safety) of the patient to fast, Shaikh Dr. Rafaqat Rasheed (General Practitioner and Islamic scholar from UK) suggests trial fasting for diabetics and patients of other chronic diseases before the month of Ramadhan (preferably in Shaban) so that they can get an idea if they can safely fast or not.
Diabetes education and Ramadhan fasting
"In all patients with diabetes, Ramadhan-focused education is of paramount importance for heightening their awareness of the possible associated risks, and formulation of effective strategies to minimise them. High-risk individuals who choose to fast should have access to ample education and support so that the potential risks, particularly those of hyper- and hypoglycaemia can be minimised. It should be emphasised that in all educational programs, optimal blood glucose monitoring should be considered as the principal consideration for minimisation of the risk of complications.
Prior to Ramadan, clinicians should perform a comprehensive evaluation and assessment for all patients with diabetes who intend to fast during Ramadan, and consider individualised approaches for their patients.
Lifestyle and diet modification can be considered as another key component of Ramadan Fasting education in individuals with diabetes. The fasting-feeding nature of the ritual can predispose diabetic patients to hypoglycaemia during the day and hyperglycaemia after iftar at night. In most Islamic cultures, consumption of high-calorie, high-fat, and carbohydrate-rich meals, confectionaries, and beverages is commonplace in Ramadan, which can adversely affect blood glucose levels and increase the risk of development of hyperglycaemia and related complications. This should be strongly discouraged in all educational programs.
Moreover, due to the high risk of hypoglycaemia and dehydration, patients with diabetes should be prohibited from strenuous exercise, particularly late in the evening and before iftar. Patients should also be informed that consumption of large amounts of high glycemic index (GI) carbohydrates and alternations in physical activity and sleeping patterns can lead to weight gain during Ramadan.
Symptoms of hypoglycaemia and hyperglycaemia should be clearly explained to diabetic patients, and they need to be thought to measure their blood sugar and immediately discontinue fasting if they develop. They also need to be advised that, in case of hypoglycaemia, a small amount of a fast-acting carbohydrate (a glass of fruit juice) should be consumed, and they need to retest their blood glucose levels again after 20 min."
"In all patients with diabetes, Ramadhan-focused education is of paramount importance for heightening their awareness of the possible associated risks, and formulation of effective strategies to minimise them. High-risk individuals who choose to fast should have access to ample education and support so that the potential risks, particularly those of hyper- and hypoglycaemia can be minimised. It should be emphasised that in all educational programs, optimal blood glucose monitoring should be considered as the principal consideration for minimisation of the risk of complications.
Prior to Ramadan, clinicians should perform a comprehensive evaluation and assessment for all patients with diabetes who intend to fast during Ramadan, and consider individualised approaches for their patients.
Lifestyle and diet modification can be considered as another key component of Ramadan Fasting education in individuals with diabetes. The fasting-feeding nature of the ritual can predispose diabetic patients to hypoglycaemia during the day and hyperglycaemia after iftar at night. In most Islamic cultures, consumption of high-calorie, high-fat, and carbohydrate-rich meals, confectionaries, and beverages is commonplace in Ramadan, which can adversely affect blood glucose levels and increase the risk of development of hyperglycaemia and related complications. This should be strongly discouraged in all educational programs.
Moreover, due to the high risk of hypoglycaemia and dehydration, patients with diabetes should be prohibited from strenuous exercise, particularly late in the evening and before iftar. Patients should also be informed that consumption of large amounts of high glycemic index (GI) carbohydrates and alternations in physical activity and sleeping patterns can lead to weight gain during Ramadan.
Symptoms of hypoglycaemia and hyperglycaemia should be clearly explained to diabetic patients, and they need to be thought to measure their blood sugar and immediately discontinue fasting if they develop. They also need to be advised that, in case of hypoglycaemia, a small amount of a fast-acting carbohydrate (a glass of fruit juice) should be consumed, and they need to retest their blood glucose levels again after 20 min."
"Drinking large amounts of water and liquids before dawn (at suhur time) should be discouraged, and instead, moderate and continuous consumption of water and beverages during non-fasting hours should be promoted."
"The advantages of the use of continuous glucose monitoring (CGM) or flash glucose monitoring (FGM) systems need to be mentioned to them, so that they procure and use them if affordable.
The type, dose, and timing of the anti-diabetic medications each patient takes is immensely influential in the management of potential risks involved in their use, but most antidiabetic agents used for treatment of type 2 diabetes are generally considered safe. It should be mentioned, however, that in patients who take several glucose lowering medications, the risk of hypoglycaemia may be amplified. Particularly, in patients who take a basal insulin in combination with a DPP4I, metformin, or other glucose lowering agents, the risk of hypoglycaemia can greatly increase."
(Ramadan fasting and diabetes, latest evidence and technological advancements: 2021 updateAli Tootee and Bagher Larijan- https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8088403/#CR3 -This article has good details about the management of type 1 and type 2 diabetes in fasting. I recommend it to all doctors treating diabetics)
