Redefining diabetes spotlight: Ramadan with diabetes - Raza Panjwani

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 part 4 of the blog series, we checked in with our dear friend Raza who was diagnosed with type 1 diabetes as an adult. We are so grateful to Raza for sharing his experience in learning how to participate in the holy month of Ramadan with the added work of also managing his blood glucose levels at the same time.

My diagnosis with type 1 diabetes as an adult in my 30s was a slow and painful process. When I first showed up at the doctor’s office with (what I later learned were) textbook symptoms of type 1, she sent me home and told me to drink more water. “You’re just dehydrated.” Fortunately, my wife wasn’t convinced and sent me back to demand lab work, which revealed a fasting glucose over 300. Fast forward three weeks, and the comedy of errors reached its peak during a follow-up appointment by phone when I asked my doctor (without fully understanding the difference) whether I might have type 1 diabetes, rather than the type 2 that ran in my family. Turns out she’d ordered antibody tests (though she hadn’t told me), and hadn’t noticed the lab results had arrived until I asked. Sure enough, I had type 1. That night, a pharmacist handed me my first vial of insulin and unhelpfully informed me “you inject it” when I asked how I was supposed to administer it. Thankfully, YouTube got me through my first injection.

My first Ramadan with type 1 came about 4 months after my diagnosis. It had been a whirlwind - I’d grappled with confusion and fear of my own body, fear of food and what it did to my blood sugar levels, and fear of insulin and what it could do to me. I’d read books about type 1, listened to type 1 podcasts, found the diabetes online community (DOC), and gotten a CGM. I was starting to feel like I was getting a handle on things.

As Ramadan approached, I was confused by all the guidance I could find on fasting with diabetes. Much of the medical guidance was understandably addressed to the much larger type 2 population, and religious guidance on not fasting if it risked my health was unhelpfully broad. What little I could find about type 1 didn’t seem to account for how technologies like CGM might make it safer to fast for someone who was insulin dependent.

And so, ignoring the well-intentioned concerns of my family, I decided I would try to fast. As it turned out, I was only able to fast for about 1/3rd of the month. I struggled with a few lows, but what I really struggled with was the high blood sugars, especially after iftar and during the night. My blood sugars were still high by sehri time and then I was worried about overshooting with my corrections during the day and having to break my fast early because of a low. I felt stuck, and ultimately called it quits because my numbers just weren’t where I wanted them to be. At that point, I was on a combination of Lantus and Humalog through multiple daily injections, and I told myself that I would try again the next year with a pump, which could deliver smaller correction doses of insulin than a pen, and would let me fine tune daytime basals.

By the following Ramadan, I was on an insulin pump and was able to keep 26 of my fasts! There were a few days where I had to break a fast to prevent or treat a low, and when my blood sugars started getting too erratic, I chose to give my body (and mind) a break before continuing. In addition to having a pump, the intervening year had taught me more about how different foods affected me, how much the timing of insulin mattered, and how to spot patterns and trends and adjust settings accordingly. There were still challenges though, like physical activity.

There were days I struggled with seeminlgy simple decisions like choosing to take my toddler on a walk to get her some outdoor time, because even that could send me low and end my fast. On the flip side, taking the variable of food out of the day almost makes diabetes less of a burden during the daytime.

Beyond the challenges fasting poses for everyone, there is an additional mental burden around the decision (and privilege) in choosing whether or not to fast with type 1 diabetes. I believe that Muslims aren’t required to fast if it puts their health in danger. But who gets to decide what is dangerous? The imam at my local center? My endocrinologist (who, to my amusement, offered to write me an excuse letter the first Ramadan after my diagnosis)? Is letting myself run a little higher than I would otherwise for a month dangerous? How long do I need to wait to see if my pump’s suspended basal delivery will turn a sinking CGM line around before breaking my fast with skittles in order to say “I tried my best” with a clear conscience?

I am in a privileged position to have access to the latest CGMs and pumps, which means I can lean on my closed loop to keep my extended highs from getting out of hand or suspend delivery to try to prevent a low, and I can intervene before a bad low because I can see it coming on my CGM graph. I look at these tools and feel that I have been granted tawfik (the ability to achieve success), which is to say, I’ve been blessed with an opportunity to observe the fasts of Ramadan safely. In return, I think it’s my duty to try for as long as I feel it’s safe, and when it’s not, I’ll bail.

I can’t speak to anyone else’s experience or put myself in anyone else’s shoes. We all know “Your Diabetes May Vary” - that managing diabetes is extremely personal. And that applies to deciding whether or not fasting makes sense too.

Just because you can doesn’t mean you should - that’s a personal decision, and only you can judge for yourself.

For me, my bottom line is my Why for observing Ramadan (or performing the daily prayers, or any other act required or recommended as a Muslim) - pursuing closeness to God. If I lose sight of that in the process, because I’m so distracted by blood sugars, then what’s the point? Fasting is supposed to be an opportunity and a blessing. If that blessing is meant for me, then it will be. If not, I have faith that God knows what’s best.