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Recommendations for management of diabetes during Ramadan: update 2020, applying the principles of the ADA/EASD consensus
  1. Mahmoud Ibrahim1,
  2. Melanie J Davies2,
  3. Ehtasham Ahmad3,
  4. Firas A Annabi4,
  5. Robert H Eckel5,
  6. Ebtesam M Ba-Essa6,
  7. Nuha Ali El Sayed7,
  8. Amy Hess Fischl8,
  9. Pamela Houeiss9,
  10. Hinde Iraqi10,
  11. Ines Khochtali11,
  12. Kamlesh Khunti2,
  13. Shabeen Naz Masood12,
  14. Safia Mimouni-Zerguini13,
  15. Samad Shera14,
  16. Jaakko Tuomilehto15,16,
  17. Guillermo E Umpierrez17
  1. 1EDC Center for Diabetes Education, McDonough, Georgia, USA
  2. 2Diabetes Research Centre, University of Leicester, Leicester, UK
  3. 3Diabetes Research Centre, University of Leicester and Leicester General Hospital, Leicester, UK
  4. 4Islamic Hospital Amman, Amman, Jordan
  5. 5Division of Endocrinology, Metabolism & Diabetes Division of Cardiology, University of Colorado Denver Anschutz Medical Campus Official Bookstore, Denver, Colorado, USA
  6. 6Dammam Medical Complex, Dammam, Saudi Arabia
  7. 7Adult Diabetes, Joslin Diabetes Center, Boston, Massachusetts, USA
  8. 8Section of Adult and Pediatric Endocrinology, Diabetes and Metabolism, University of Chicago Medicine, Chicago, Illinois, USA
  9. 9Division of Endocrinology, American University, Beirut, Lebanon
  10. 10Faculty of Medicine and Pharmacy, Mohamed V University, Rabat, Morocco
  11. 11Department of Endocrinolgy and Internal Medicine, University of Tunisia, Monstair, Tunisia
  12. 12Obstetrics & Gynecology, ISRA Medical University, Karachi, Sindh, Pakistan
  13. 13Pierre & Marie Curie Center, University of Algiers, Algiers, Algeria
  14. 14Diabetic Association of Pakistan, Karachi, Pakistan
  15. 15Chronic Disease Prevention Unit, National Institute for Health and Welfare, Helsinki, Finland
  16. 16Dasman Diabetes Institute, Kuwait City, Kuwait
  17. 17Medicine, Emory University, Atlanta, Georgia, USA
  1. Correspondence to Dr Mahmoud Ibrahim; mahmoud{at}


Fasting the Holy month of Ramadan constitutes one of the five pillars of the Muslim faith. Although there is some evidence that intermittent fasting during Ramadan may be of benefit in losing weight and cardiometabolic risk factors, there is no strong evidence these benefits apply to people with diabetes. The American Diabetes Association/European Association for the Study of Diabetes consensus recommendations emphasize the importance of patient factors and comorbidities when choosing diabetes medications including the presence of comorbidities, atherosclerotic cardiovascular disease, heart failure, chronic kidney disease, hypoglycemia risk, weight issues and costs. Structured education and pre-Ramadan counseing are key components to successful management of patients with diabetes. These should cover important aspects like glycemic targets, self-monitoring of blood glucose, diet, physical activity including Taraweeh prayers, medication and dose adjustment, side effects and when to break the fast. The decision cycle adapted for the specific situation of Ramadan provides an aid for such an assessment. Children with type 1 diabetes should strongly be advised not to fast due to the high risk of acute complications such as hypoglycemia and probably diabetic ketoacidosis (DKA), although there is very little evidence that DKA is increased in Ramadan. Pregnant women with diabetes or gestational diabetes should be advised to avoid fasting because of possible negative maternal and fetal outcomes. Hypoglycemia is a common concern during Ramadan fasting. To prevent hypoglycemic and hyperglycemic events, we recommend the adoption of diabetes self-management education and support principles. The use of the emerging technology and continuous glucose monitoring during Ramadan could help to recognize hypoglycemic and hyperglycemic complications related to omission and/or medication adjustment during fasting; however, the cost represents a significant barrier.

  • endocrinology diabetes
  • gestational diabetes mellitus
  • nutrition

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  • Contributors MI determined the manuscript strategy, wrote the first draft, he also wrote a section about Egypt and fixed the coauthors’ comments on each version; MJD, EA and KK wrote a section about the ADA/EASD consensus and the related figures; FAA wrote a section about Jordan; RHE wrote a section about children with type 1 diabetes; EMB-E wrote sections about intermittent fasting and also section about Saudi Arabia along with dates consumption; NAES wrote a section about pregnancy; AHF wrote a section about nutrition and hypoglycemia; PH wrote a section about Lebanon; HI, IK and SM-Z wrote a section about north Africa; SNM and SS wrote a section about Pakistan; JT and GEU provided intellectual content in interpreting data and critically reviewed the manuscript. All authors revised and approved the final version of the manuscript.

  • Funding This research was supported by the National Institute for Health Research (NIHR) Leicester Biomedical Research Centre (BRC), the NIHR Leicester Clinical Research Facility (CRF) and the NIHR Applied Research Collaboration East Midlands (ARC–EM).

  • Disclaimer The views expressed are those of the author(s) and not necessarily those of the NHS, the NIHR or the Department of Health and Social Care.

  • Competing interests None declared.

  • Patient consent for publication Not required.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data availability statement All data relevant to the study are included in the article. De-identified participant data.