Al-Arouj et al. (1) have made recommendations for fasting during the holy month of Ramadan for Muslim diabetic patients. The recommendations were drafted by an expert panel of diabetologists from around the globe, and it represents a landmark for practicing clinicians who look after diabetic Muslims. The recommendations were based on expert opinion rather than evidence-based scientific research, which, as the panel pointed out, is lacking in this area. These provisional recommendations await well-designed research aimed specifically at seeing whether fasting is beneficial or harmful to patients with type 1 diabetes.

Type 1 diabetic patients are often advised not to fast by physicians. The nature of type 1 diabetes makes fasting hazardous. Thus, type 1 diabetic patients are put in the category of very high risk in the recommendations. Evidence-based scientific data will definitely help physicians caring for such patients to decide whether to advise patients with type 1 diabetes strongly or half-heartedly about fasting.

Patient education regarding fasting during the holy month of Ramadan is badly needed. Research in this area is also deficient. In a recent study, only 33% of our diabetic patients received general advice on fasting during Ramadan (2). Morbidity related to fasting has been reported to be quite high. The rates of severe hypoglycemia and hyperglycemia were alarmingly high in the Epidemiology of Diabetes and Ramadan study, a population-based large epidemiological study that spanned 13 countries with sizeable Muslim populations (3). Such a high rate of fasting-related morbidity was reported earlier in a small study by Uysal et al. (4). Education of patients is the cornerstone of safe fasting, which is needed on both an individual and large-scale level, and this is the responsibility of diabetes care team members.

Diabetic patients with established renal disease run substantial risk of complications by fasting and rightly the recommendations put them in the high-risk category. The great majority of those patients have major comorbidities and are taking many drugs, including insulin and sulfonylurea agents, which make them prone to severe hypoglycemia. We feel that these patients need to be singled out more specifically in the guidelines as such groups, even those who receive renal replacement therapy, often insist on fasting (A.A.A.-A., unpublished observations). Fasting for prolonged periods, especially in hot climates, may impose negative impacts on renal function from hypovolemia and dehydration. The mainstay of management of those patients is targeted toward arresting the progression of their underlying renal disease, and fasting during Ramadan should not be recommended.

Another group that deserves special consideration is adolescent patients with type 1 diabetes. These patients should not be encouraged to fast, as recurrent severe hypoglycemia may have grave consequences, especially on neurobehavioral development (5,6,7). We feel that this group should have been pointed out categorically.

Finally, we commend the efforts of the expert panel, which took the painstaking task of drafting these long-awaited recommendations. Taking the issue of Ramadan and diabetes further warrants randomized controlled studies to explore the perceived benefits and expected risks of fasting, which will provide the scientific platform for future updated recommendations. Only when this is coupled with mass educational campaigns to patients with diabetes will the expected benefits from fasting be fulfilled.

Al-Arouj M, Bouguerra R, Buse J, Hafez S, Hassanein M, Ibrahim MA, Ismail-Beigi F, El-Kebbi I, Khatib O, Kishawi S, Al-Madani A, Mishal AA, Al-Maskari M, Nakhi AB, Al-Rubean K: Recommendations for management of diabetes during Ramadan.
Diabetes Care
Elhadd TA, Bissar LS, AlGhamdi SM, Bashir M, Alulaqi N, Al Amoudi A: Low education provided to patients with diabetes for fasting the holy month of Ramadan: a questionnaire survey (Abstract). In 187th American Endocrine Society Annual Meeting, San Diego, California, 4–7 June 2005. Chevy Chase, MD, The Endocrine Society
Salti I, Benard E, Detournay B, Bianchi-Biscay M, Le Brigand C, Voinet C, Jabbar A, EPIDIAR Study Group: A population-based study of diabetes and its characteristics during the fasting month of Ramadan: results of the Epidemiology of Diabetes and Ramadan 1422/2001 (EPIDIAR) study.
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Uysal AR, Erdogan MF, Sahin G, Kamel N, Erdogan G: Clinical and metabolic effects of fasting in 41 type 2 diabetic patients during Ramadan (Letter).
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