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Diabetes & Ramadan

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Diabetes & Ramadan 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 quantification 2 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% 10–20% • Dates: 1–2* • Dates: 1–2 • Dates: 1–2 • Dates: 1–2 1500 kcal 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.
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