DIABETES MANAGEMENT DURING RAMADAN

Times to measure blood sugar throughout the day: 1. Before Suhoor (4 AM) 5. Before Iftar (sunset) (8 PM) 2. Morning (8 AM) 6. After Iftar (12 AM) 3. Mid-day (12 PM) 7. Anytime there are hypoglycemia/ 4. Mid-afternoon (4 PM) hyperglycemia symptoms or not feeling well

Know when to break your fast: Go to the hospital emergency

 Blood sugar <70 mg/dl or hypoglycemia* symptoms, room if very ill: re-check within 1 hour if blood glucose 70-90 mg/dL  Multiple episodes of vomiting (more than 2)  If hyperglycemia with ketones in urine, or if  Low blood glucose (below 150) after drinking sugary symptomatic.** It’s important to stay hydrated. beverages AND positive ketones (small, moderate or  When feeling sick and experiencing cold/flu like large) symptoms.  Abdominal pain *Symptoms of Hypoglycemia: Trembling, Sweating/chills,  Breathing problems Palpitations, Hunger, Altered mentation or Confusion, Headache  Unable to drink fluids and going to the bathroom less frequently or stops urinating – (signs of dehydra- **Symptoms of Hyperglycemia: Extreme thirst, Hunger, tion) Frequent Urination, Fatigue, Confusion, Nausea/Vomiting, Abdominal Pain  Appears more sleepy or difficult to wake

Patients with Type 1 diabetes (T1DM) who have any of the following conditions are strongly advised not to fast:  History of recurrent hypoglycemia  Hypoglycemia unawareness  Poor diabetes control  Uncontrolled blood sugars  Non-compliance with medical treatment  Unable to regularly monitor and manage their blood glucose levels

1 Dietary Recommendations Exercise Recommendations

 Advise to eat fiber rich, low-glycemic index carbs (e.g. A reasonable level of physical activity should be fruits, vegetables, whole grains, beans, nuts, and dairy). maintained during Ramadan, with consideration to avoid strenuous exercise in the hours before Iftar when  Limit intake or serve a smaller portion of traditional hypoglycemia is most likely. desserts and high glycemic index carbs (e.g. white bread, white rice, low-fiber cereal, white potatoes)

 Sugary drinks, syrups, and canned/fresh juice with added sugar should be avoided.

 Choose lean protein sources, like fish, skinless poultry, diary products, nuts, seeds, and beans.

 Minimize intake of high saturated fat foods (beef, lamb, butter, ghee, cream, processed meat, fried food)

 Incorporate more monounsaturated and polyunsaturated fats (e.g. avocado, extra virgin olive oil, vegetable oil, fish, olives, nuts and seeds).

 Accurate carbohydrate counting at pre-dawn (Suhoor) and sunset (Iftar) meals enables correct insulin doses for best glucose control.

 Hydration should be maintained by drinking water and other non-sweetened drinks at regular intervals during non-fasting hours.

 Minimize intake of caffeinated beverages (tea, coffee, soda) because they act as diuretics, which can lead to dehydration.

 The pre-dawn meal (Suhoor) should be as late as possible, especially if fasting for longer than 10 hours.

 The Suhoor meal should include a larger portion of protein and low-glycemic index carbs to help decrease hunger during the day.

 Begin Iftar with plenty of water to rehydrate after fasting and have 1-3 small dried or fresh dates to help raise blood glucose levels.

2 Better Choices: Fruits & Vegetables Commonly Food Serving Size Carbohydrate** Eaten Foods Dried Figs 2 figs (28 g) 16 g 1 date (19 g) 6g Fresh dates During Ramadan 3 dates (57g) 18g 1 date (6 g) 5 g Dried deglet date 3 dates (18 g) 15 g Dried Medjool date 1 date, pitted (24g) 18 g 1 half (6 g) 2 g Dried apricot 8 halves (48 g) 18 g Sultanas Snack pack (40 g) or ¼ cup 30 g

Dried barberries ¼ cup (37 g) 20 g

Poor Choices: Cakes, Pastries & Sweets*

Food Serving Size Carbohydrate** Chocolate-Arabian Delights 1 piece (11 g) 7 g (chocolate coated dates with nut inside) Mouhalabieh (Milk flans) 1 cup (200 g) 30 g

Galactobureko (filo custard pastry, syrup soaked) 1 piece (2 in x 2 in) 28 g

Baklava 1 piece (50 g) 26 g

Turkish Delight 1 piece (18 g) 15 g

Kanafeh 1 square, 6 tablespoons (120 g) 40 g

Halva (nut butter-based e.g. tahini) 2 tablespoons (50 g) 22 g

Ghraybeh (butter cookies) 1 cookie (15 g) 7 g Ma’mool / maamoul / ma’moul 1 cookie (35 g) 23 g (cookies stuffed with walnuts/dates) Basbousa (sweet semolina cake soaked in syrup) 1 slice (30g, 3 cm x 3 cm) 14 g

Sekerpare (butter cookie soaked in syrup) 1 piece (18 g) 16 g

Tulumba (fried dough soaked in syrup) 1 piece (35 g) 37 g

Lokma (sweet fried dough) 1 ball (13 g, 2 cm) 10 g

* May have more saturated fats. **Carbohydrate amounts are best estimates and may vary by brand or method of food preparation. Using a food scale to measure the weight of the food in grams can help with accurate carb counting. 3 Example Plate

https://www.idf.org/our-activities/education/diabetes-and-ramadan/healthcare-professionals.html

Carb Needs for Ramadan Based on Calorie Needs

Calories per day 1500-1600 1800 2000

Carbs per day 170-190g 200-225g 225-250g

Suhoor Carbs 50-80g 60-90g 70-100g

Iftar Snack Carbs 20-40g 20-45g 20-50g

Iftar Meal Carbs 70-100g 80-115g 90-125g

2nd Snack Carbs 20-40g 20-45g 20-50g

Males ages (years) 9-10 11-12 13+

Females ages (years) 9-13 14-18 18+

https://www.idf.org/our-activities/education/diabetes-and-ramadan/healthcare-professionals.html 4 1500-1600 1800 calories/day calories/day

https://www.idf.org/our-activities/education/diabetes-and-ramadan/healthcare-professionals.html 5