Diabetes & Ramadan

Contents

1. Risk quantification 4

2. Blood glucose monitoring 4

3. When to break the fast 5

4. Fluids and dietary advice 6

5. Exercise advice 14

6. Medical adjustments 15 Diabetes & Ramadan

Fasting during the holy month of Ramadan forms one of the five fundamental pillars of Islam. Muslims abstain from food and drink from dawn (Suhur) to dusk (Iftaar).1

Estimates suggest that there are 148 million Muslims with diabetes worldwide, of whom over 116 million may fast during Ramadan.2

Many Muslims with diabetes mellitus still choose to fast even though those who are ill are exempt from this obligation.1

It is important to note that fasting poses many risks:2

Key risks associated with fasting for patients with diabetes2

Hypoglycaemia Hyperglycaemia

Diabetic Dehydration ketoacidosis and thrombosis RISKS

It is for these reasons that it is very important that, as a diabetic patient, you need to be assessed by your doctor two to four months before Ramadan, so that changes can be made to your regular diabetes regimen.1

2 Your doctor will give you more information regarding the following topics:

Key components of a Ramadan-focused educational programme2

1. Risk quantification

3. When to 2. Blood break the glucose fast Key monitoring components of a Ramadan-focused educational 6. Medication programme 4. Fluids and Adjustments dietary advice

5. Exercise advice

3 4. Risk quantification2

Your doctor will assess your potential risk and will deliver customized management to ensure optimal care is delivered. You should be provided with the appropriate knowledge and support to minimise the risks you face. This is even more important if you are a Type 1 diabetic, elderly or pregnant.

2. Blood glucose monitoring2

• It is important to test your blood sugar regularly during Ramadan • This will help you to identify episodes of hypoglycaemia (low sugar) or hyperglycaemia (high sugar) • Your doctor will advise you when to test depending on your risk and what medication you are on • If you are on insulin or sulphonylureas, you may have to test more often because of the increased risk of hypoglycaemia (low blood sugar) associated with these medicines • It’s important to test after iftar to see how the meal has affected your blood sugar levels • Always check sugar levels when you experience symptoms of hypoglycaemia (low sugar), hyperglycaemia (high sugar), dehydration, or if you feel unwell and be prepared to break the fast if necessary

4 3. When to break the fast

All patients should break their fast if: • Blood glucose less than 3.9 mmol/L • re-check within 1 hr if blood glucose 3.9 - 5.0 mmol/L • Blood glucose more than 16.6 mmol/L* • Symptoms of hypoglycaemia, hyperglycaemia, dehydration or acute illness occur

Hypoglycaemia Hyperglycaemia Dehydration 5

• Trembling • Extreme thirst • Increased thirst • Sweating / chills • Hunger • Dry mouth & swollen tongue • Palpitations • Frequent urination • Weakness • Hunger • Fatigue • Dizziness • Altered mental status • Confusion • Palpitations (pounding heart) • Confusion • Nausea / vomiting • Confusion • Headache • Abdominal pain • Fainting

* Consider individualisation of care

5 4. Fluids and dietary advice

Dietary advice for patients with diabetes during Ramadan2

• Divide daily calories between suhoor and iftar, plus 102 snacks if necessary • Ensure meals are well balanced - 45 - 50% carbohydrate - 20 - 30% protein - <35% fat (preferably mono-and polyunsaturated) • Include low glycaemic index, high fibre foods that release energy slowly before and after fasting - eg. Granary bread, beans, rice • Include plenty of fruit, vegetables and salads • Minimise foods that are high in saturated fats. eg. Ghee, samoosas, pakoras • Avoid sugary desserts • Use small amounts of oil when cooking. eg. Olive, rapeseed • Keep hydrated between sunset and sunrise by drinking water or other non-sweetened beverages • Avoid caffeinated and sweetened drinks

Daily caloric intake distribution during Ramadan2

Percentage of total calories / day Suhoor 30 - 40 % Iftar 40 - 50 % Snack between meals (one or two, if necessary) 10 - 20 %

6 Example of a Ramadan plate2

1 glass of low fat milk

1 cup of vegetables 4 oz of lean protein

1 2 dates

1.5 cup of whole grain rice cup of beans/lentils/peas

1 small slice 2 teaspoons of oil of watermelon

This meal provides: 770 kcal, 45% carbohydrate, 20% protein and 35% fat

*Plate to be adapted according to the individual’s daily caloric target

7 A South African Ramadan nutritional plan2

Ramadan nutrition plan Tool kit (Algorithm 2) Ramadan nutrition application for South Africa

Target daily Macronutrient Caloric calories composition distribution 1200 kcal/day 1500 kcal/day 1800 kcal/day 2000 kcal/day • CHO: 45–50% Suhoor 300–480 kcal 450–600 kcal 540–720 kcal 600–800 kcal Recommended: 30–40% • Wholegrain bread: 1 slice, with egg: • Wholegrain bread: 2 slices, with egg: • Wholegrain bread: 2 slices, with egg: • Wholegrain bread: 2 slices, with egg: low GI, low GL, 1 large 1 large 1 large 1 large 1200 kcal whole grain and • Milk: 4 tbsp, with oats: 3 tbsp, and • Milk: 4 tbsp, with oats: 3 tbsp, and • Milk: 4 tbsp, with oats: 3 tbsp, and • Milk: 4 tbsp, with oats: 6 tbsp, and Weight reduction high bre almonds: 0.5 handful almonds: 0.5 handful almonds: 1 handful almonds: 1 handful for women • Protein: 20–30% • Apple: 1 small • Apple: 1 small • Yoghurt: 0.5 tub • Yoghurt: 0.5 tub <150 cm tall Recommended: • Water/unsweetened drinks • Water/unsweetened drinks • Apple: 1 small • Apple: 1 small sh, skinless (400 kcal, CHO exchange = 3)† (475 kcal, CHO exchange = 4) • Water/unsweetened drinks • Water/unsweetened drinks poultry, dairy, (555 kcal, CHO exchange = 4.5) (640 kcal, CHO exchange = 5.5) nuts, seeds and legumes Snack 1 120–240 kcal 150–300 kcal 180–360 kcal 200–400 kcal Fat: <35% 1500 kcal • 10–20% • Dates: 1–2* • Dates: 1–2 • Dates: 1–2 • Dates: 1–2 Recommended: Badam milk (milk, ground almonds: Badam milk (milk, ground almonds: Badam milk (milk, ground almonds: Badam milk (milk, ground almonds: Weight SFA <10%, • • • • maintenance 0.5 handful and cardamom powder): 0.5 handful and cardamom powder): 0.5 handful and cardamom powder): 0.5 handful and cardamom powder): choose low-fat 1 glass 1 glass 1 glass 1 glass for women cooking methods (210 kcal, CHO exchange = 2) (210 kcal, CHO exchange = 2) (210 kcal, CHO exchange = 2) (210 kcal, CHO exchange = 2) <150 cm tall and e.g. grill, bake weight reduction and steam for women Iftar 480–600 kcal 600–750 kcal 720–900 kcal 800–1000 kcal >150 cm tall Lifestyle 40–50% • Dates: 1–2* • Dates: 1–2 • Dates: 1–2 • Dates: 1–2 recommendations • Baked mince samosas: 2–3 cocktail • Baked mince samosas: 2–3 cocktail • Baked mince samosas: 2–3 cocktail • Baked mince samosas: 2–3 cocktail • Haleem (wheat, oats and meat • Haleem (wheat, oats and meat • Haleem (wheat, oats and meat • Haleem (wheat, oats and meat • Begin iftar with broth): 0.5 cup broth): 1 cup broth): 1 cup broth): 1.5 cups Basmati/parboiled rice: 0.5 cup/ Basmati/parboiled rice: 0.5 cup/ Basmati/parboiled rice: 1 cup/ Basmati/parboiled rice: 1 cup/ 1800 kcal plenty of water • • • • to overcome roti: 1 small roti: 1 small roti: 2 small roti: 2 small Weight maintenance dehydration Grilled or curried lean chicken/ sh: Grilled or curried lean chicken/ sh: Grilled or curried lean chicken/ sh: Grilled or curried lean chicken/ sh: for women • • • • from fasting 4 oz 4 oz 4 oz 4 oz >150 cm tall & Green salad/vegetables‡ Green salad/vegetables Green salad/vegetables Green salad/vegetables weight reduction • Keep physically • • • • for men active • Water/unsweetened drinks • Water/unsweetened drinks • Water/unsweetened drinks • Fruit: 1 whole piece • Do not sleep for (490 kcal, CHO exchange = 3) (635 kcal, CHO exchange = 4) (710 kcal, CHO exchange = 5) • Water/unsweetened drinks longer than usual (850 kcal, CHO exchange = 6)

Snack 2 120–240 kcal 150–300 kcal 180–360 kcal 200–400 kcal 10–20% • Unsweetened fruit in fruit juice: • Milk-based dessert with sweetener • Milk-based dessert with sweetener • Milk-based dessert with sweetener 0.5 cup (phirmi/falooda/ras malai): 0.5 cup (phirmi/falooda/ras malai): 1 cup (phirmi/falooda/ras malai): 1 cup 2000 kcal • Water/unsweetened drinks • Water/unsweetened drinks • Water/unsweetened drinks • Water/unsweetened drinks Weight maintenance (120 kcal, CHO exchange = 1) OR OR OR for women Unsweetened fruit in fruit juice: 1 cup, Unsweetened fruit in fruit juice: 1 cup, Unsweetened fruit in fruit juice: 1 cup, >150 cm tall & • • • and custard with sweetener: 0.5 cup and custard with sweetener: 0.5 cup and custard with sweetener: 0.5 cup for men • Water/unsweetened drinks • Water/unsweetened drinks • Water/unsweetened drinks (160 kcal, CHO exchange = 1.5) (235 kcal, CHO exchange = 2.5) (235 kcal, CHO exchange = 2.5)

*If dates are consumed during snack 1, no dates should be consumed during iftar. †One CHO exchange = 15 g CHO. ‡Increased consumption of green salad and vegetables is encouraged up to 3 cups daily; starchy vegetables should be measured (1 small potato = 1 exchange of CHO) CHO, carbohydrate; GI, glycaemic index; GL, glycaemic load; GTSN, glycaemia-targeted specialised nutrition; SFA, saturated fatty acids; tbsp, tablespoon

8 Ria Catsicas, a registered dietician, recommends some helpful tips for Ramadan

Delicious Date Balls

(makes 30 depending on size)

• 250g Dates, chopped • 80ml Canola margarine • 30ml Castor sugar • 30ml Sugalite • 1 Large egg yolk, beaten • 5ml Vanilla essence • 1 Packet digestive biscuits, crushed • 100g Crushed almonds

Method: 1. Combine the dates, margarine and sugar in a pot until the margarine melts. 2. Mix in the egg and vanilla essence. 3. Mix in the crushed biscuits. 4. Allow the mixture to cool, and then roll into balls and then roll in crushed almonds.

Analysis per Date Ball: Energy 360 kJ, Protein 0.8 g, Fat 3.3 g, Carbohydrate 11.6 g, Sugar 3.8 g, Sodium 78 mg

Bhaji Cake

(makes +/- 15 squares depending on size)

• ¾ Cup chana flour • ½ Cup mealie meal • ½ Cup canola oil • 3 bunches methi bhaji chopped • 2 Teaspoons sesame seeds • 1 Medium onion grated • 5 Sticks spring onions chopped • 1 Teaspoon baking powder • 1 Teaspoon salt • ½ Cup low-fat milk • 3 Teaspoons green chili • 1 Teaspoon ginger/garlic • ½ Cup sweetcorn 9 Method: 1. Mix everything together and pour into greased pan. 25cm x 15cm. 2. Sprinkle 2 teaspoons sesame seeds and bake at 180 °C for 45-50 minutes until brown on top. 3. Cut into squares and serve hot.

Analysis per Bhaji Cake (30 g): Energy 313 kJ, Protein 1.3 g, Fat 4.2 g, Carbohydrate 6.9 g, Fibre 1.1 g

Moong Dhal Bhajias

(makes +/- 12 bhajias)

• 1 Cup moong dhal soaked overnight • 1 Medium onion (chopped) • 1 Tablespoon chana fl our • 1 Teaspoon baking powder • 1 Teaspoon salt • 1 Teaspoon ground coriander • 1 Teaspoon pounded green chilies • ¼ Teaspoon fine chilies (powder) • 1 Tablespoon fine chopped coriander leaves • 1 Tablespoon fine chopped shallot • 1 Tablespoon canola oil

Method: 1. Wash dhal well, removing all outer skin. Drain well. Grind it twice through a mincer. 2. Add spices, onion, greens and chilies. Mix well until frothy, adding a tablespoon of chana flour if mixture is too watery. 3. Take ping pong ball sizes of the moong dhal mixture and pat roundly and firmly in the palmof your hand to 1 cm thickness. Put a tablespoon of oil in the pan and brown well on both sides, instead of deep frying.

Analysis per Moong Bhajias (3 x15g): Energy 261 kJ, Protein 3.0 g, Fat 2.1 g, Carbohydrates 5.3 g, Fibre 2.5 g

10 Laapsi (crushed wheat)

• 1 Cup laapsi (crushed wheat) • ¼ Cup canola oil • 2 Pieces of cinnamon sticks • 1 Teaspoon elachi (crushed) • ¼ Cup sugar light • 2½ Cups water • 4 Almonds, finely cut

Method: 1. Braise laapsi in oil with cinnamon sticks and elachi till golden brown on low to medium heat. 2. Add water and cook on low heat till laapsi is soft and cooked. Add sugar light and cook till it is well absorbed. 3. Decorate with 4 almonds finely cut and serve while hot.

Analysis per serving of Laapsi (2 tablespoons): Energy 153 kJ, Protein 0.3 g, Fat 2.0 g, Carbohydrates 3.58 g, Fibre 5 g

Chocolate Balls

(Makes 15)

• 2 Cups desiccated coconut • ½ Cup brazil nuts • ½ Cup Huletts SUGAlite • ¼ Cup cocoa powder • ¼ Cup butter, melted • 1 Tablespoon vanilla • 1 Pinch of salt

Method 1. Place all ingredients together in a food processor and process until a dough like consistency. 2. Shape into rounds. 3. Put in the fridge for a minimum of 2 hours (ideally 6 hours) to cool.

11 Carrot and Bran Muffins

(Makes 12 muffins)

• 125 ml (½ c) Wholewheat/ Original Pro Nutro • 125 ml (½ c) Oats • 250 ml (1 c) High-fibre cereal – All Bran • 250 ml (1 c) Cake flour • 250 ml (1 c) Digestive bran (wheat bran) • 5 ml (1 t) Cinnamon • 2 ml (½ t) Salt • 5ml (1 t) Baking powder • 7 ml (1½ t) Bicarbonate of soda • 120 ml (½ c) Sultanas/ raisins • 1 Small apple or firm pear, grated • 1 Cup finely grated carrots • 2 Eggs • 5 ml (1 t) Vanilla essence • 30 ml (2 T) Sunflower oil • 125 ml (½ c) Huletts SUGAlite • 375 ml (1 ½ c) Low fat milk

Method 1. Preheat oven to 220 ˚C. 2. Mix all the dry ingredients and add the sultanas, the grated apple or pear and the carrots. Mix gently. Keep to one side. 3. Beat the egg, vanilla essence, oil and Huletts SUGAlite together in a large bowl. 4. Add to the dry ingredients. Mix gently, but thoroughly. 5. Spoon the batter into greased pan, slightly overfilling each muffin hollow, and place into the hot oven. 6. Turn the oven temperature down to 180˚C and bake for 20-25 minutes. 7. Insert a skewer in the centre of a muffin to check whether it is cooked. If there is any raw batter on the skewer, bake for another 5 minutes.

Eat the muffins on the same day, as they do not keep well because of their high moisture content. Alternatively, freeze and defrost them individually as needed.

Analysis per muffin Glycaemic Index 56, Carbohydrates 25 g, Protein 5 g, Fat 3 g, Fibre 5 g, 641 kJ

12 Sugar-Free Shoji

(Makes 6 portions)

• 1 Cup Tasty wheat dry cereal • 1½ Cup water • 1½ Cup low-fat milk • 2 Tablespoons ghee • ¾ Cup Hulletts SUGAlite • 1 Tablespoon elachi powder • 2 Tablespoons almond flakes

Method 1. Boil the water and milk together 2. Add the Hulletts SUGAlite, stir and keep on one side 3. In a large pan heat the ghee over medium heat and add the Tasty wheat cereal 4. Sauté till golden brown, while constantly stirring with a fork 5. Slowly pour the water and milk in and mix well 6. Cook for another 4 minutes until the water is absorbed and thickened – while stirring 7. Add the elachi powder and mix 8. Decorate with the almond flakes and serve hot or cold

Analysis per portion Energy 600 kJ, Carbohydrates 23 g, Protein 4 g, Fat 4 g

Sugar-Free Trifle

(Makes 8 portions)

• 40g (½ packet) Diabetic or sugar-free red jelly powder • 40g (½ packet) Diabetic or sugar-free green jelly powder • 200g Sponge cake or Madeira cake or Swiss roll cake • 1 x 410g Weigh-Less canned fruit (fruit canned in juice) • 67,5ml (4 flat tablespoons) Custard powder • 12,5ml (1 dessertspoon) Hulletts SUGAlite • 500ml Low-fat milk

13 Method 1. Pour each colour of the jelly powder in 2 bowls 2. Add ½ cup boiling water to each and stir 3. Add ½ cup cold water to each jelly, stir and put in the fridge to set 4. Heat 450ml low fat milk 5. Mix the custard powder with the Hulletts SUGAlite and 2 tablespoons milk to a paste 6. Add the custard powder to the hot milk and stir till it thickens. Leave to cool down 7. Cut the cake as well as the canned fruit into cubes 8. Make the trifle by layering the following ingredients and put in the refrigerator to set: - cover the bottom with ½ the cake, followed by ½ the canned fruit. Sprinkle a bit of the canned fruit juice on the cake. This is followed by the 2 coloured jellies and custard, repeat the layers with the remaining cake, fruit, jelly and top with a final layer of custard

Analysis per portion Energy 880 kJ, Carbohydrate 35 g, Protein 4 g, Fat 6 g

With all these healthy dishes and advice your Ramadan will be a pleasant, delicious and healthy (well-controlled blood sugar) experience. Remember selecting healthier foods and enjoying smaller portions will leave you feeling energetic and will not detract from the delicious tastes that the meals of Iftar, Suhur and Tarawhee offer.

5. Exercise advice2

Although rigorous exercise is not recommended during fasting because of the increased risk of hypoglycaemia and/or dehydration, patients with diabetes should be encouraged to take regular light-to-moderate exercise during Ramadan. Patients should be reminded that the physical exertions involved in Tarawih prayers, such as bowing, kneeling and rising, should be considered part of their daily exercise activities.

14 6. Medication adjustments2

Adjustments to the dose and/or timing of some medications may be required during Ramadan to minimise the risk of hypoglycaemia. Your doctor will evaluate and make changes to your current treatment plan if needed.

Your individual plan as decided upon by your doctor:

Medication changes: ______

15 Eating recommendations: ______

Other: ______

16 References:

1. Amod A, Ascott-Evans BH, Berg GI, Blom DJ, et al. JEMSDA 2012;17(2)(Supplement 1):S1-S95 2. Diebetes and Ramadan: Practical Guidelines. International Diabetes Federation (IDF), in collaboration with the Diabetes and Ramadan (DAR) International Alliance. April 2016. 3. Derrer T. Dehydration in Adults. 2013. WebMD. Available from: http://www.webmd.com/ a-to-z-guides/dehydration-adults?print=true#. Accessed 26.04.2017

Free mobile application

“DAR SaFa” for patients to manage Diabetes in Ramadan

More Information on DAR: https://www.daralliance.org/daralliance/ sanofi-aventis south africa (pty) ltd., Reg. No. 1996/010381/07. 2 Bond Street, Grand Central Ext.1, Midrand,1685. Private Bag X207, Midrand 1683. Tel: (011) 256 3700. Fax: (011) 256 3707. www.sanofi-aventis.com SAZA.TJO.20.02.0048