Redefining diabetes spotlight: Ramadan with diabetes - Dr. Himala Kashmiri

Last year, I had the opportunity to share my personal perspective and experience with fasting during Ramadan with type 1 diabetes. This year, we wanted to check in with other members of the community to see how they participate in Ramadan while also doing the work of an organ to manage blood sugars. This is a mini blog series that will include the perspectives of different members of the community that celebrate Ramadan in their own way - because we know there is no one size fits all approach to anything related to diabetes.

Key terms that will be used throughout this series include:

• Sehri/Suhoor - the pre-dawn meal before starting your fast.
• Iftar - the meal you break your fast with at sunset.
• Eid - a day of celebration at the end of Ramadan.
• Fidya - a religious donation of money or food to help those in need when a fast cannot be observed.

For this part of the blog series, we checked in Dr. Himala Kashmiri from Children's Health of Orange County to get his insight as a clinician on fasting with diabetes.

Fasting with insulin dependent diabetes is a very individual decision, and thankfully the current state of technology which includes sensors and sensor augmented pump therapy makes the experience more feasible. In my clinical opinion, we can use what we already know about how people are fasting while they sleep and apply that to fasting during the day instead. We just need to adjust caloric intake (and corresponding settings) for sehri (the daily pre-dawn meal before beginning your fast) and iftar (the meal to break your fast after sunset) times.

Before sehri, wake up and eat like you typically would and be sure to hydrate as much as possible to help prevent your body from entering a state of ketosis. If you are using a continuous glucose monitor, then watch those numbers. If not, then monitor your blood sugars every 3-4 hours to make sure you are staying in a safe range. If you experience any signs of low blood sugar, then check sooner and break your fast if you are low. Use that experience to make adjustments to your basal or long acting dose accordingly. My suggestion is to start with a 20% reduction in basals or long acting dose for the first couple of days to see how that works out - and adjust if you need to be more or less aggressive accordingly. If you plan on fasting this year, here are some key takeaways:

• Try a 20% reduction in basals/long acting dose.

• Make sure you have a good intake of carbs, protein, and fat and hydrate at sehri to sustain yourself.

• Closely monitor blood sugars and ketones and adjust accordingly.
• Low blood sugars and/or moderate to high ketones are grounds to break your fast.

Fasting with diabetes is attainable.

I strongly advise against prolonged fasting (no sleeping in through sehri!) because this can be extremely dangerous. Ketones are caused by a lack of insulin and dehydration, so adjusting your caloric intake and your hydration to make sure your body gets what it needs to prevent ketosis during sehri and iftar is key to a successful fast with diabetes. The first few days of fasting can be used to check in on ketone levels and adjust hydration and insulin accordingly. If your blood sugars are ok but you are still seeing ketones, it could mean that you need to drink more water at sehri and see if that makes a difference.

Diabetes should fit around your life instead of the other way around.

If your life goal includes fasting and observing the month of Ramadan, there is a way to do it - and to do it safely. It just takes a little bit of closer monitoring.

We’re so grateful for the time Dr. Kashmiri spent with us sharing his insights from his clinical experience in working with patients with diabetes over the years. If you would like to learn more about how Tidepool can support you and the rest of your clinical team, please visit provider.tidepool.org.