Category 2: High risk. Patients in this category have type 2 diabetes with sustained poor glycemic control, type 2 diabetes controlled with multiple-dose or mixed insulin regimens, well-controlled type 1 diabetes, pregnancy with type 2 diabetes controlled by diet or metformin, stage 3 chronic kidney disease, and/or stable macrovascular complications. This category also includes people with diabetes who perform intense physical labor and those being treated with drugs that may affect cognitive function. These patients should listen to medical advice and should not fast.
Category 3: Moderate/low risk. Patients at moderate or low risk have well-controlled type 2 diabetes treated with lifestyle or pharmacotherapy. While patients in this category should follow medical advice, they may use their discretion to fast based on medical opinion and their individual ability to tolerate fasting. Patients who do fast should receive structured education, regularly self-monitor blood glucose levels, and follow recommendations for medication adjustments.
Regardless of what category a patient falls into, safety risks related to driving must be assessed.2 Dr Ghouri and colleagues compared British secular law with Shari’ah Islamic law, categorizing agreements and differences between them. Currently, the issue of driving and fasting during Ramadan in patients with diabetes is not specifically addressed by the United Kingdom Driver and Vehicle Licensing Agency; however, general guidance for driving with diabetes is provided.
“From a biomedical perspective,” noted the review, “the twofold to sevenfold increase in risk of hypoglycemia with diabetes and fasting requires strict adherence to [Driver and Vehicle Licensing Agency] precautions if driving.”2
Guidance provided by the Qur’an states that Islam both supports and permits exemptions from fasting for those with appropriate ailments.2 When counseling patients, clinicians should keep in mind that Islamic tradition provides guidelines for Muslims to opt out of certain practices, including fasting, to preempt potential individual harm.2 Shari’ah laws also recognize secular legal requirements for public good, such as the care and safety of others using the road.
In cases for which a patient is advised that it is safe for them to drive, or when a patient with diabetes chooses to fast despite medical advice, there are several scenarios to consider to guide both clinicians and patients in their decision making:2
· Is the patient driving out of necessity, need, or choice?
· What if the patient develops symptoms of hypoglycemia?
· Must a patient experience a minimum number of hypoglycemic episodes before fasting while driving is deemed inappropriate?
· What if a patient chooses to drive, but must stop driving because of hypoglycemia symptoms or blood glucose readings?
· Should special considerations be made for patients who drive, for example, trucks or buses?
· What are the ramifications if a patient chooses to drive, despite being advised to not do so?
If appropriate, people with diabetes can undertake a trial fast prior to Ramadan. These fasts may provide useful evidence to both patients and clinicians to steer decision making during Ramadan. In their review, Dr Ghouri and colleagues also provided a discussion pathway for clinicians and patients when making decisions around Ramadan fasting2:
Before Ramadan. Clinicians should ensure that patents are appropriately evaluated for the presence or absence of any factors that would affect driving while fasting. If patients choose to fast, advise them on any relevant diabetes management guidelines.
During Ramadan. Patients should, as a rule, avoid all unnecessary journeys. If patients must drive, they should avoid long trips, early morning trips, driving within 2 hours of sunset or driving during bad weather. Encourage patients to keep hypoglycemia treatments on hand, even while fasting. Emphasize that patients with blood glucose ≤5 mmol/L should carry appropriate snacks. Those with blood glucose ≤4 mmol/L, or who feel hypoglycemic, should not drive; hypoglycemia should be promptly addressed.
Counsel patients to be aware of their hypoglycemia warning signs. Remind patients how to handle a hypoglycemic episode while driving: patients should safely stop the vehicle, turn off the car and remove the keys from the ignition, and then remove themselves from the driver’s seat. Patients should consume a fast-acting carbohydrate and should not resume driving until 45 minutes after blood glucose has returned to normal.
After Ramadan. Patients and clinicians should review their experiences and outcomes. In particular, clinicians should review the risk-benefit ratio of the chosen fasting strategy on an individualized level. Clinicians should also consider potential ensuing legal implications.
“As with all doctor-patient encounters involving religious beliefs and practices, discussion of Ramadan fasting is not complete without a bioethical consideration despite the claimed differences between Western and Islamic ethics,” Dr Ghouri and colleagues noted in their review. While physicians must respect patient autonomy, physicians must also practice nonmaleficence.
Clinicians should recognize the important role they play in cross-cultural discussions. One large multinational study found that people with diabetes who received Ramadan-specific guidance were more likely to follow Ramadan-specific diabetes management recommendations.4 Other data suggest that Muslims may “choose to fulfill their religious obligation despite being discouraged by their doctors.”5 In these cases, collaboration between religious authorities and clinicians should be explored in order to ensure that patients receive adequate education.
“The tetrad of diabetes, fasting during Ramadan, hypoglycemia and safe driving stimulates a challenging discussion with potential legal ramifications,” Dr Ghouri and colleagues concluded. “Given that for many Muslims fasting is an important part of their individual life as well as in engendering community spirit and bonding, healthcare professionals should continue to adopt a patient-centered approach when engaging in discussion.”
1. Ghani F. Most Muslims say they fast during Ramadan. Pew Research Center. July 9, 2013. https://www.pewresearch.org/fact-tank/2013/07/09/global-median-of-93-of-muslims-say-they-fast-during-ramadan. Accessed June 28, 2019.
2. Ghouri N, Hussain S, Mohammed R, et al. Diabetes, driving and fasting during Ramadan: the interplay between secular and religious law. BMJ Open Diabetes Res Care. 2018;6:e000520.
3. Hassanein M, Al-Arouj M, Hamdy O, et al; for the International Diabetes Federation in collaboration with the Diabetes and Ramadan International Alliance. Diabetes and Ramadan: practical guidelines. Diabetes Res Clin Pract. 2017;126:303-316.
4. Ahmedani MY, Alvi SFD. Characteristics and Ramadan-specific diabetes education trends of patients with diabetes (CARE): a multinational survey (2014). Int J Clin Pract. 2016;70(8):668-675.
5. Lee JY, Wong CP, Tan CSS, Nasir NH, Lee SWH. Type 2 diabetes patient’s perspective on Ramadan fasting: a qualitative study. BMJ Open Diabetes Res Care. 2017;5(1):e000365.