Redefining diabetes spotlight: Ramadan with diabetes - Mohammed Seyam

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 with Mohammed Seyam, a diabetes educator and medical student in Gaza. Mohammed was kind enough to share his experience as someone who has been living with diabetes since he was 12 years old along with how his insight as a future clinician helps him manage his diabetes and fast during Ramadan.

I was diagnosed with type 1 diabetes right before I turned 12. I honestly don’t remember a lot about the specific techniques I used to make sure that I was safe while fasting after my diagnosis, I just fasted and it went well - I am very lucky that I haven’t ever faced any complications or difficulties. Over the years, there have been days where I was unable to fast because of hypoglycemia, but diabetes has never been a reason to stop participating in this aspect of my faith.

Over the last 3 Ramadans, I rarely had to break any of my fasts. My schedule in the past has allowed me to fall asleep after suhoor until about dhuhr (the afternoon prayer). I would wake up around noon and test, and if I find that my blood sugar is around 200 mg/dL - I would give myself a small correction dose that I have figured out works for my body through experimentation. This is to make sure I don’t stay in the 200s for hours. Per the IDF Diabetes and Ramadan clinical guidelines, it is not advised to continue fasting if I go over 300 mg/dL and hypoglycemia or hyperglycemia are grounds to break my fast. I did a lot of experimenting to figure out how to adjust my dosages for my body over the month. Since I am on long-acting insulin, I thankfully don’t have to worry about ketones in the same way that a patient on an insulin pump does. Many guidelines I have come across preferably suggest that fasting patients use long-acting insulin precisely for this reason.

I have the privilege of being an educator and healthcare provider, so I know a lot about how and what to eat and how my body works during fasting hours as a diabetic. As someone who has experimented and knows what does and doesn’t work for me, it is easier for me to fast during Ramadan and I am in a safer position than most people. I know it is not obligatory for me, but it is one of the 5 pillars of my religion, so after familiarizing myself with the clinical guidelines, why wouldn’t I at least try?

Because diabetes management is so personal, my advice to the type 1 patients I work with is to experiment before the month of Ramadan. Working with your medical team, conduct a personal pre-assessment to figure out what does and doesn’t work beforehand so you are as prepared for the month as possible. Before Ramadan, I change my diet when I am at the clinic so that I am eating low carb, like veggies and salads to help prep my body. My favorite form of exercise is usually powerlifting, which is perfect for someone with diabetes because it means your muscles are growing 24/7 and that helps reduce insulin resistance. But I can’t go to the gym during Ramadan, so I start cutting that out of my routine earlier on so that I can adjust my insulin dosages to accommodate for the change in my insulin sensitivity. Instead, I go for walks during Ramadan - usually right before iftar to stay active and compensate for the lack of activity. Then if I go low, it is just in time! It is very hard for me to give this up, but I know I need to prepare my body.

At iftar time I don't just go and have my iftar after maghrib (the prayer at sunset). I drink soup, for example, go and get a date. Then I take my insulin, pray and wait for 15 minutes to give my pre-bolus some time and lower the risks of hyperglycemia. Depending on my personal pre-assessment, I reduce my long-acting dosage accordingly. When I was on NPH, I used to take two doses, one at iftar time and another at suhoor time. I found that I needed to reduce my suhoor dose otherwise I would experience hypos. Since switching to Lantus, I have found that I don’t really need to reduce my dosage by as much as when I was on NPH.

When Allah gives us permission, that means He would like us to not fast more than He would like for us to resist and fast anyway.

The extra work of the personal assessment before Ramadan is necessary before deciding whether or not to fast, so you can know if your body can safely go through the ordeal.

You need to know how your body is going to react and modify accordingly. If you can’t make the necessary adjustments, and the act of fasting is going to compromise your health - then you should not do it.

In my community, patients do not visit their endocrinologist to talk about making adjustments to their dosages or how to change their treatment plans for Ramadan. Self-adjusting medication can be extremely risky, but here - it is very difficult for people to visit an expert about the particulars of what they should adjust. It is rare for patients with type 2 diabetes to check their blood sugar regularly here in Gaza. UNRWA (United Nations Relief and Works Agency) only authorizes test strips for patients with type 1, but not type 2. Another hurdle is that in order to get medications from UNRWA or the Ministry of Health, they need a detailed patient history and a prescription from an endocrinologist. But the doctors in primary clinics are general practitioners, or family doctors, not endocrinologists - so they do not have the detailed information and experience with diabetes management and dosage adjustments.

For anyone that is unable to get the medical guidance necessary to safely fast, or for anyone that it just isn’t possible for, I understand the feeling of missing out on something special. Parents should always work with an endocrinologist that is using the Diabetes and Ramadan guidelines for clinicians. For children with diabetes who feel like they are missing out on something their friends are going through, I would suggest waking up for suhoor and participating in as many aspects of Ramadan as possible. Have iftar earlier in the day instead and experience Ramadan in your own way. It is important for all Muslims with diabetes to feel included in all the other aspects that make Ramadan special. Allah grants us mercy by giving us permission to not do this hard thing. He knows our intentions and rewards us for them.