Fasting and feasting is an integral part of many religions and cultures, both of them posing unique challenges to the diabetes patients. Lifestyle modifications along with proper treatment dose adjustment or modification are thereby inevitable to ensure a safe fasting or feasting period and to reduce the complications.

Fasting and feasting are the common practices observed by people as a regimen for traditional or cultural reasons. Fasting is generally found in different forms and frequencies according to the religion. The Hindus observe fast during Navratri, Ekadashi, Purnima, and Pradosha; Muslims do Roza during Ramadan; Jains keep ekasana or upavas during Paryushana; Buddhist take Vassa, and Christians observe Lent fast before Easter. Depending on the religion and festival in context, fasting may last from one day to one month, or it may be periodic, frequent, infrequent, or complete.

Diabetes mellitus is a progressive metabolic disorder, highly prevalent in India. It can be assumed that a considerable number of patients with diabetes in India observe fasting and feasting during festivals. During fasting and feasting, diabetes patients are prone to high risk of complications.

Hence management of diabetes during this religio-cultural practice is highly inevitable. And with, appropriate lifestyle modifications including diet and physical activity, nutrition plans, pre-fast counselling and structured diabetes education along with proper treatment, dose adjustment or modification it is possible to reduce complications.

In the coming years, the ratio will increase with an increase in diabetes prevalence, erratic food habits and sedentary lifestyle. Pertinent management strategies during fasting and feasting might reduce the complications and improve the quality of life in people with diabetes in India.

Although fasting may be safe, tolerable, and decreases body weight in diabetes patient, it should be individualised according to the patient history, comorbidity status, and diabetes medications.

According to an international consensus, patients with T1DM and unstable T2DM (with or without complications), pregnant women and elderly patients with diabetes should not observe fast. However, stable patients with T2DM with or without oral-antihyperglycaemic agents (OADs) could follow the fast with proper planning and strict management. Thus, patients have been stratified into different risk categories according to their comorbid status, continued medication, health status etc.

Management of diabetes during fasting and feasting

Pre-fast medical assessment and patient counselling enables a safe and protected fasting in patients with diabetes.

• The benefit to the risk associated with fasting, patient medical history, present disease state, physical examination, continued medication, discomforts during fasting and their prevention strategies, and a brief management plan should be discussed during the counselling
• Medical assessment should include the measurement of glycaemic levels (haemoglobin and HbA1c), estimation of blood pressure and lipids, and a total annual review along with specific advice on potential harms of fasting
• The patient should be made aware of the hypo- and hyper-glycaemic episodes and factors that influence these episodes, and how to self-manage them during the fasting period
• After assessing all the details, the physician should advise the patient on whether to fast or to seek exemption; however, the decision should follow person-centeredness and emotion and belief of the patient

Structured diabetes education plays a vital role in improving knowledge regarding diabetes and its complication management, and helps the people for making informed decisions during fasting.The Ramadan Education and Awareness in Diabetes (READ) study determined the impact of Ramadan-focused education on weight and hypoglycaemic episodes in T2DM patients. The structured diabetes education programme should be intended for both patients along with their families, and healthcare professionals.

Several oral antidiabetic agents such as metformin, sulfonylureas, DPP-4 inhibitors, SGLT-2 inhibitors, thiazolidinedione, alpha-glucosidase inhibitors, and, injectable agents such as insulin and insulin analogues, and GLP-1 receptor agonists are in use for the management of T2DM in India.

Due to disturbance in eating timings, sleep and wakeful pattern, T2DM patients who are continuing antidiabetic medications require some dose adjustment/modification during their fasting and feasting period.

Post-fast debriefing

Post-fast briefing enables the organization of future strategies in order to combat several metabolic disorders. Patients with diabetes and observing fasts should share their experience related to physical and mental health, symptoms, complications, steps taken to prevent complications, and about their quality of life during the fasting period.

Controlling diabetes with a specific management strategy during fasting and feasting period is obligatory and it improves patient’s quality of life. Several antidiabetic drugs require dose modification during the fasting and feasting period. Furthermore, these modifications should be done according to the type, frequency, and days involved in fasting. Hypoglycaemia is a major concern for patients on insulin and SUs.

Disclaimer- The views and opinions expressed in this article are those of the author's and do not necessarily reflect the official policy or position of M3 India.

The author, Dr. Banshi Saboo is a Senior Diabetologist from Ahmedabad.