(1) should be allowed to fast if they decide to;

(2) can fast safely;

(3) can be helped to fast if they decide to;

(4 ) can have their disease monitored at home; and

(5) are going to derive any benefit or harm to their health.

Fasting during Ramadan by a Muslim diabetic patient is neither his right nor Islamic obligation, but only a privilege to be allowed by his physician, at the patient's request, knowing all the dangers and assuming full responsibility in dietary compliance and glucose monitoring, with good communication between the physician and the patient.

Psychological state of diabetes during Ramadan

Diabetes mellitus itself adversely affects patients' psychological states by changes in glucose metabolism, blood and CSF osmolality, needs for discipline and compliance, fear of long term complications and threat of hypoglycemic attacks (state of unconsciousness affecting diabetics) and the possibility of dehydration and coma.

On the other hand, fasting during Ramadan has a tranquilising effect on the mind, producing inner peace and decrease in anger and hostility. Fasting Muslims realise that manifestations of anger may take away the blessings of fasting or even nullify them.

Diabetics know that stress increases the blood glucose by increasing the catecholamine (the hormones adrenaline and noradrenaline which are released by the adrenal glands) level and any tool to lower the stress; i.e., biofeedback or relaxation improves diabetic control. Thus, Islamic fasting during Ramadan should have a potentially beneficial effect with regard to diabetic control.

Check list for diabetics
Patients should be taught home glucose monitoring, checking urine for acetone, doing daily weights, calorie-controlled diabetic diet, need for sleep and normal exercise. They should be able to take pulse, temperature, look for skin infection and notice changes in the sensorium (mental alertness). They should be on special alert for any colicky pain, a sign for renal colic (sudden pain caused by kidney stone or stones in the ureter), or hyperventilation, a sign of dehydration, and to be able to seek medical help quickly rather than wait for the next day.

Exercise of diabetics during Ramadan
Diabetic patients should avoid heavy exercise during fasting hours. It is better to exercise after iftar or meal at night. Saying tarabih prayer is a good way of exercise.

Change of dosages for diabetics during Ramadan

• Diabetic patients who take oral hypoglycemic drug once daily, should take the medicine immediately after iftar at a low dose.
• Patients who take oral medicine more than one time daily should reschedule the dose in the morning and at night (of regular time) respectively to after iftar and 30 minutes before sehri.
• Patients who take insulin, should adapt the dosage schedule of insulin prior to Ramadan after consulting with a diabetologist. Usually long-acting basal insulin (Insulin Glargin, available in our countyr in the trade name Lantus) is safe and recommended during Ramadan fasting. It should be administered after iftar at a higher dose and at sehri time at a lower dose. Other medication of diabetes should be continued as per the advice of the physician.

Preparation for Ramadan fasting
Knowing about diabetes completely is an important component of diabetes control.

We should keep in mind that the same management policy is not applicable for each individual. This is why patients should know their own state of diabetes very well. And people should consult with doctors whether they are able to fast during Ramadan at their body condition or not.