Tyler Basen shares how he fares as a patient with diabetes and gives some tips for clinicians
by Tyler Basen, MD – Contributing Writer, MedPage Today
This article is a collaboration between MedPage Today® and: THE ENDOCRINE SOCIETY

There are several holidays that may make it difficult for people with diabetes to control their blood sugar. Holidays are supposed to be quality time spent with family and friends so it’s only reasonable for patients to be frustrated during these times whether fasting or even when an abundance of food is part of the celebration. As more of a “cultural Jew” I still take part in many of the major holidays and a particularly difficult one for me is Yom Kippur.
Yom Kippur in Judaism is considered the holiest day of the year as it is the Day of Atonement where you repent for your sins and participate in a 25-hour fast. Even before I was diagnosed with type 1 diabetes, this obviously was not an easy task. But add two different insulins and frequent blood sugar checks into the mix and it can seem quite impossible. My goal in this article is to provide some information and to emphasize that for those of us with diabetes can enjoy the holidays without falling victim to blood sugar madness.
The danger of fasting in acute setting
I will first start by stating that under Jewish law it is okay to refrain from fasting because of a primary health concern. Fasting can be extremely dangerous in the acute setting because of the risk for hypoglycemia and even hyperglycemia.
Ramadan is another holiday where fasting is part of the observance. In fact, a study showed that 43% of people with type 1 diabetes and 79% of people with type 2 diabetes in 13 Islamic countries fast during Ramadan. Another study underscores this by showing a correlation between adequate glycemic control before Ramadan in adolescents with controlled glucose profiles during the fast. Endocrinologists should counsel their patients about fasting and discuss an individualized plan and any medication adjustments.
These and other studies have pointed out that that the risk of being hospitalized for hypoglycemia during a fast can range from a threefold to a more than fourfold higher risk in people with T1D. It is important to explain to patients that if their diabetes is currently not under control, it is recommended that they do not participate in the fast.
Making a fast more manageable for those with diabetes
I have fasted for an extended period of time and can provide some recommendations to make it more manageable. First, the biggest mistake by far is for patients to not take their 24-hour or long-acting insulin such as Lantus either the night before or the morning of a fast. This is similar to the trap of withholding Lantus prior to an upcoming surgery. Doing this will only significantly increase the risk of severe hyperglycemia, as basal insulin is needed to counteract stress hormones such as adrenaline and cortisol. I normally take 12 units of Lantus at night and even if I just eat a late lunch, I will become mildly hypoglycemic. This works for me however, because ordinarily I stick to a regimented meal schedule. I believe it also helps with hyperglycemic fluctuations particularly post-prandial because my fasting sugar prior to a meal is not already on the higher side such as 140-150mg/dl. Other people with diabetes may take slightly less basal insulin and may not become hypoglycemic if they are forced to eat lunch at 3 p.m. Thus, this individualized approach is crucial to understand before attempting to adjust basal insulin during a fast for Yom Kippur or Ramadan.
What adjustments should be made to basal insulin dosing before a fast?
Unfortunately, there is no right answer to this because it is different for every person with diabetes. I have tested different regimens so before an extended fast trial and error is important. For me, decreasing from 12 units to approximately 8 units or a 33% reduction was appropriate for a full day fast. One study followed diabetes patients on insulin pump therapy during a Ramadan fast and concluded the basal insulin regimen during the fast either remained unchanged or decreased by 5.5% to 25.0%. Thus, as a general statement if a person with diabetes is more prone to hypoglycemia with even short fasts then a larger reduction in the basal regimen should be anticipated for a 24-hour fast.
What other precautions can be made to prevent severe complications during a fast?
During Yom Kippur, I did not refrain from drinking water. I believe this to still be a respectable way to participate in a fast because it still shows sacrifice by refraining from eating. Becoming dehydrated can have so many adverse health outcomes for those with diabetes that I did not want to put myself at risk. Severe dehydration can make you more prone to diabetic ketoacidosis (DKA) and have harmful effects on the kidneys. Other precautions include having family or friends close if help is needed and to check your blood sugar multiple times throughout the fast. Additionally, always keep glucose tablets or granola bars nearby if severe hypoglycemia occurs and end the fast if needed. It’s important to let patients know that while it’s important to share the holidays with family, there is no shame in protecting their own health.

Expert Critique
FROM THE ENDOCRINE SOCIETY Reading Room

Religious fasts of varying durations, such as those mentioned in this article—Ramadan and Yom Kippur—are examples of holiday practices that can have a significant impact on both the belief systems and self-care of patients with diabetes. This article references some data for type 2 diabetes, but has particular focus on unique issues that affect those with type 1 diabetes, mainly managing basal insulin and preventing DKA with adequate hydration.

As emphasized by Dr. Basen, fasting can cause significant hypoglycemia or hyperglycemia that can be treated and, more importantly, potentially prevented with some planning. He stresses the need for patients to adjust, but not hold or forget to take, basal insulin. Since each patient is different, as described in the reference regarding insulin pump changes during Ramadan, individual tailoring of insulin dosing is imperative as people with diabetes have a wide range of underlying insulin resistance and sensitivity.

An overarching theme of the article is that patients with diabetes and their providers should work together to find a balance between the socio-religious importance of a holiday fast on family and the individual psyche while preserving good blood glucose control throughout the fast. Preventing severe hypoglycemia, hyperglycemia, DKA, and dehydration is possible. Patients with diabetes can preserve the significance of a religious fast, but also do everything possible to prevent complications caused by the absence of food or too much insulin.