A Matter of Life

Fasting and Feasting

Dr Ambrish Mithal is chairman and head, Endocrinology and Diabetes Division at Medanta, The Medicity, Gurgaon
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Can religion and diabetes go together?

CELEBRATING festivals by fasting or feasting (or both) has been an ancient practice in India, recommended virtually by every major religion. ‘Upavaasa’ is the Sanskrit word for fasting; ‘upa’ means ‘near’ and ‘vaasa’ means ‘to stay’. Fasting therefore means ‘to stay near’ (the lord).The practice of fasting ranges from light food restriction to extreme abstention. It could be overnight (sunset to sunrise) or all day (sunrise to sunset), and with varying frequency— monthly, fortnightly, weekly or twice a week. It could also be for extended periods, like during Navratri or Ramzan.

Fasting is considered trendy these days because of the perception it helps lose weight and control blood sugar. But is fasting advisable for diabetics? This depends on the type of diabetes, the kind of treatment being received, the level of sugar control and the status of diabetes-related complications, particularly those involving the heart, kidney or liver.

Prolonged fasting with diabetes can lead to hypoglycemia— when blood glucose level falls below 70 mg/dl, leading to sweating, trembling, increase in heartbeat, mental confusion, and can proceed to loss of consciousness if untreated. This is particularly true if the diabetic is taking treatment. Fasting is more often than not followed by feasting, leading to hyperglycemia or high blood glucose as people tend to indulge in calorie-dense fried and sweet food after breaking their fast. Another complication may be owing to abstinence from liquids, as people may get dehydrated, particularly if they are on drugs that pump out water from the body (diuretics), common for treating high blood pressure.

Of all the religious fasts, Ramzan represents a particular challenge. The norms of observing roza during Ramzan are strict and often (like this year) the month of Ramzan falls during peak summer. During this period Muslims abstain from food, drinks and oral medications from dawn (sehri) to sunset (iftar). Ideally, diabetics who wish to fast during Ramzan should consult a doctor and get their medicines adjusted beforehand. For the last few weeks—like every year before Ramzan—I have been flooded with my Muslim patients seeking advice about managing diabetes. I do not advise fasting for the elderly, pregnant women, those with poorly controlled diabetes or those with complications like kidney, liver or heart disease. People having Type 1 diabetes (insulin-dependent), history of recurrent low blood sugar and diabetic coma (ketoacidosis) should also avoid fasting. On the other hand, those who manage diabetes well with a healthy lifestyle alone, without any medicines, can fast without much difficulty. However, individuals who are on multiple oral medications and/or insulin should consult their doctors to adjust their medicines prior to fasting. During Ramzan, the larger dose of medicine should be taken at iftar, which is the major meal of the day; a lower dose is advisable at sehri. In general, metformin and gliptins (sitagliptin, vildagliptin, linagliptin and teneligliptin) are safe as they do not cause low blood sugar reactions. Sulphonylureas (glimepiride and gliclazide) can cause a drop in blood glucose which, at times, can be dangerous. Newer medicines like SGLT2 inhibitors (canagliflozin, empagliflozin, Dapagliflozin) should be used with caution during Ramzan because they increase the risk of dehydration.

At the end of a hot and often tiring day, people tend to overeat food rich in fat and simple carbohydrates like samosa, pakoda and sharbat when they break their fast. Instead, one should eat fibre- rich bran rotis, oatmeal, pulses/lentils, vegetables and fruit. It is important to drink more water or fluids during the non-fasting hours. Normal levels of physical activity can be maintained during fasting but the duration and time of physical activity can be modified according to the fasting regimen. Physical activity should be reduced during fasting, particularly before iftar. It is essential to monitor blood glucose levels throughout the day. This is especially critical for those taking insulin. Terminate the fast if your blood sugar drops below 70 or rises above 300 mg/dl. If approached the right way, Ramzan is also a great opportunity to improve health by managing weight and blood glucose and giving up smoking.

Fasting is one of the most ancient and widespread healing traditions. The Greek physician Hippocrates, considered the father of modern medicine, wrote: ‘To eat when you are sick is to feed your illness.’ In fact, ancient Greeks believed fasting also improves cognitive abilities.

New research suggests caloric restriction confers health benefits like reduced risk of cancer, heart disease, diabetes and overall slowing of the ageing process, confirming the wisdom of ancient religious leaders and physicians. If people with diabetes follow simple health rules, they not only fulfil their religious obligations, but can also derive health benefits.