Fasting and diabetes

Those suffering from type 2 diabetes may be worried about observing the fast during the Muslim month of Ramadan. However, it is possible to fast safely if you are careful about managing your diabetes. A recently study concludes that most people with well-controlled type 2 diabetes can safely observe the fast. The study was published in the uly 2!!" issue of Clinical and Experimental Hypertension . #evertheless, it is important for those with diabetes to ta$e care, since some drugs that are used to treat type 2 diabetes, such as sulphonylureas and insulin, can ma$e your blood glucose level drop too low when you are not eating. #ot drin$ing enough water can also ma$e you dehydrated. %ften the evening meal, iftar , contains lots of carbs and perhaps sugary drin$s. &ecause this is a time when families eat together to brea$ the fast, the food may be richer than what you might normally eat. And having fasted all day, you may feel you have an e'cuse to reward yourself, but you need to be particularly strong willed at this time(

Fasting checklist:

Seek the advice of your healthcare team before starting and at the end of the fast, since they may advise you to change the frequency or amount of medication you take. Do not stop taking your medication, however the dosing and timing of your medication may need to change this should be discussed with your diabetes healthcare team prior to fasting. If you experience symptoms of low blood sugar levels such as sweating, anxiety, shaking, weakness or confusion then you should break your fast with a sugary drink followed by foods rich in carbohydrates. void eating lots of unhealthy foods as a reward! Instead, try and maintain a healthy eating pattern after you break the fast. "ake sure that you have lots of fruit and vegetables and dhal as these are slowly digested and help your blood glucose to rise more slowly too. lso remember to drink plenty of fluids. Divide your daily food intake into two equal portions, one to be taken at sehri and one at iftar . #e sure to check your glucose level regularly $ at least once a day at different times of the day.

)ollowing Ramadan, visit your doctor to ma$e sure that your blood glucose is being controlled ade*uately, and also to chec$ whether your medication needs to be ad+usted.

Ramadan and Diabetes

%amadan is a month long period of fasting

There is often discussion about whether people with diabetes should fast during Ramadan or not. Ramadan is a month long period of fasting during the daylight hours. )asting during Ramadan is underta$en to promote chastity and humility and as an act of submission to Allah. Ramadan ta$es place on the ,th lunar month of the -slamic calendar. As a result, the date varies amongst the western ./regorian0 calendar.

Is fasting with diabetes dangerous to health?

)asting during Ramadan could compromise one1s health. Those on blood glucose lowering medication should consult their /2 about whether it will be safe for them to fast and what precautions can be ta$en to prevent blood glucose levels from going either too low or too high. 3ontinuing to ta$e blood glucose lowering medication during the daylight hours of fasting may present a particular ris$ of low blood glucose4 hypoglycemia . 5uring the hours of night, when the day1s fast can be bro$en, the body may need to ta$e in more food than would normally be eaten, as a result, this may lead to higher blood glucose levels during the night time hours.

Should people with diabetes fast during Ramadan?

2eople are recommended not to fast if the act of fasting could negatively affect their health. The charity, 5iabetes 67 , advises people with e'isting diabetic complications not too fast. 2eople with type 8 diabetes should not stop ta$ing their insulin as this could lead to a dangerous condition called diabetic $etoacidosis . However, fasting whilst continuing to ta$e insulin could lead to hypos so people with type 8 should see$ the advice of their consultant or diabetologist before ta$ing part in fasting.

%ther people which may be e'empt from fasting include pregnant women, the elderly and those suffering an illness. Those who cannot fast during Ramadan may be e'pected to donate meals to the poor and needy. 9ou may wish to spea$ with your -mam about how best to respect the fasting period. &e sure to chec$ with you doctor if you ta$e part in the fast.

Controlling your blood sugar levels through Ramadan

It is advisable to test your blood sugar levels more often than normal through %amadan. #e aware of the symptoms of high and low blood sugar . &ave your testing kit ready if you notice you may be either too high or low on sugar. If you are taking blood glucose lowering medication, make sure you have a form of quickly absorbed sugar with you. See below for which foods are good options for eating at Iftar 'the break of fasting(.

FASTING IT! "IA#$T$S% S!()*" +N(

!AT $&$R' "IA#$TIC

)asting with diabetes is a condition which every diabetic should $now. :i$e most diabetics, you try to deal with your disease proactively. 9ou have regular chec$-ups, ta$e your medications as prescribed, e'ercise on a regular basis, and try to stic$ to a stringent diabetic diet . ;o what do you do if you want or need to eat fast< ;ince both healthy and diabetic people may have reasons to fast from time to time, it1s important for diabetics to understand what effects fasting can have on their overall health and well-being before attempting to do so. &ut first, let1s ta$e a loo$ at what fasting involves and the main reasons people do it for. )asting normally involves going without food, drin$, and sometimes medications for e'tended periods of time ranging from 82-2= hours. 6nder that definition, fasting can be *uite challenging, especially for those with diabetes. As to why people fast, there are a number of reasons. Many people fast for religious reasons, including special Holidays. 2atients are also often re*uired to fast before certain blood tests, prior to ma+or surgeries, and before other procedures such as colonoscopies. %nce it is established that you will be fasting, and you are a diabetic patient, you should consult with your physician to determine if it is safe for you to fast and how to correctly go about it because fasting with diabetes can be dangerous if you are not well aware of certain facts.

-f you are fasting for religious reasons, you will most li$ely find that it is perfectly fine not to do so, especially if safety issues are involved>the $inds of issues your doctor has already made you aware of. 2regnant women with gestational diabetes should not fast because it is unsafe to do so. %ther reasons not to fast for religious purposes are if you have recently suffered a heart attac$, you have a cold, the flu or some other infection or if you have a difficult time controlling your blood sugar under normal non-fasting conditions. ;hould your doctor give you the go ahead to fast for religious reasons, ma$e sure he or she understands the nature and duration of your fast and that you understand what medications should or should not be ta$en during your fasting period. 9our doctor will also tell you to chec$ your blood sugar often, and instruct you as to what to do if your blood sugar gets too high or too low. ;hould your blood sugar begin dropping too low at any time during your fast, you should stop fasting immediately. ;ome good advice for those who are fasting for a blood test, surgery, colonoscopy or other medical procedure, is to try to schedule your test or procedure the first thing in the morning. &y getting in early you will not need to fast any longer than you absolutely have to. %nce you have been cleared for fasting, the ne't big *uestion that should be on your mind is? @ HOW WILL FASTING AFFECT MY DIABETES MEDICINE? A As a diabetic, you have done your homewor$, and you $now the role that insulin plays in regulating blood sugar. 9ou should also $now that if you refrain from eating or drin$ing for prolonged periods, insulin will cause your blood sugar to get too low. The same rule applies for many diabetic medications that are ta$en at mealtimes. Ma$e sure your prescriber goes over each of your meds and clearly notates which ones you should or should not ta$e, either right before or during the duration of your fast. &eing that fasting tends to change the rules on blood sugar control, your doctor may also alter the dose of your diabetic drugs .the dose will usually be lower0 as well as the time of day you should ta$e them. ;ince your prescriber will probably not be with you to loo$ for trouble signs while you are fasting, the ne't *uestion you should as$ is? @ WHAT THINGS SHO LD I WATCH O T FO! WHEN I FAST? A Answer to that *uestion, here are some of the things you need to watch for when fasting. )irst and foremost, that blood sugar you $eep such a close eye on each and every day may get too low during a fast. Ma$e sure you chec$ your blood sugar often. As you may already $now from e'perience, low blood sugar can ma$e you feel nauseated, sha$y, confused, cold and sweaty. 9ou may also e'perience a rapid heartbeat that can be fairly scary. That1s why before you fast you need to as$ your prescriber two critical *uestions, the first being, what blood sugar number is too low for you< The second and most critical *uestion is, what do you do if your blood sugar gets too low< As to the 8st *uestion, that number can depend on a number of factors, but in general terms, blood glucose numbers between B! and ,!mgCdl are considered red flags for low blood sugar .hypoglycemia0. Dhenever you fast, always $eep a good sugar source with you at all times, such as fruit +uice, glucose tablets, hard candies, or crac$ers, +ust in case your blood sugar drops too low. As strange as it may seem, abnormally high blood sugar during fasting can pose a real problem for other types of diabetics. )or people with type 8 diabetes, this scenario can be

e'tremely dangerous. -f you have type 8 diabetes, rely on your prescriber to tell you what insulin ad+ustments to ma$e while fasting. Although you still need to ta$e some insulin, the dose will usually be lower. )inally, it cannot be emphasiEed enough how important it is that you consult your physician if you have diabetes and plan to fast for any length of time. )or those with or without diabetes, mounting evidence shows that fasting can be a cleansing and healthy e'perience for your body. The $ey for diabetics is to fast as safely as possible. "LEASE SHA!E YO ! THO GHTS AND #IEWS: -f you are a diabetic and you also fast from time to time, what precautions you ta$e so as to avoid messing up with your health< 2lease do share your views and thoughts with the readers which may help many people in similar conditions. -f you li$e this post and want to have top health tips, fitness tips and fitness regime tips, you can subscribe to )RFF Health n Fitness Ca$e feed via EMAIL to get instant updates on health and fitness information.

Fasting Safely With Diabetes

Fasting when you have diabetes ,an be ris-y. with your health ,are provider is a must. or-ing

)asting can be a challenge for anyone, but it can be especially difficult for someone with diabetes. As any diabetic $nows, successful blood sugar management relies on healthy meals eaten at regularly spaced intervals. ;o what happens when one or more meals need to be s$ipped for religious reasons or because of a medical or dental procedure< Fach individual1s situation is different, so consultation with your physician is crucial. That said, there are some general guidelines that can help when it comes to fasting with diabetes. Dia%etes an& Fasting: D'es T()e Matte$? Dhether you have type 8 or type 2 diabetes, fasting needs to be approached with care. G)asting should be rare if you have diabetes because an individual with type 8 or type 2 on oral medication can e'perience hypoglycemia .low blood sugar0,G says Amy 7ranic$, a certified diabetes educator with 5iabetes 3are 3lub in #ashville, Tenn. Ris$s from low blood sugar include seiEure, coma, or even death if left untreated. %n the other hand, depending on the individual, fasting without using insulin can result in high blood sugars or in diabetic $etoacidosis .a serious diabetes complication caused by

blood build-up of acids called $etones0. 5ehydration is another fear if fluids are avoided during the fast. Dia%etes an& Fasting: D'es the !eas'n Make a Di**e$ence? That being said, people with diabetes may want or need to fast for a variety of reasons, and the length of the fast can affect what actions you need to ta$e. Here are some e'amples?

!eligi'+s $eas'ns, ;ome people with diabetes may want to fast for religious observances such as 9om 7ippur or Ramadan. /iven the ris$y nature of fasting with diabetes, this isn1t necessarily a good idea. G&oth H udaism and -slamI have guidelines that e'empt those people who will be affected with harmful health conse*uences by fasting,G says Toby ;mithson, R5, certified diabetes educator in &uffalo /rove, -ll., and a spo$esman for the American 5ietetic Association. G-n the ewish religion, it is considered a mitEvah .a good deed0 if one must eat for health reasons.G -f you1re determined to fast, consult with your doctor or diabetes educator to put a plan in place at least a month or two before the actual fast. Medication dosage should be discussed, as well as how often to test your blood sugar and what to do if your blood sugar is too low or too high. Also, $eep in mind that the fasting itself may not be the only issue to plan for. Medication timing is also important. G5uring religious fasts you may be able to eat a meal at various times .pre-dawn or sunset0, which can affect when you need to ta$e insulin or oral medication to control your blood sugars,G says Megan Robinson, M;, R5, a certified diabetes educator at the 3hildren1s Hospital of 2hiladelphia. Me&ical tests '$ )$'ce&+$es, ;ometimes fasting is unavoidable, as in the case of medical or surgical procedures and certain lab tests. GThis type of fast is short-term and poses much less ris$ than a prolonged fast such as Ramadan,G says 3onstance &rown-Riggs, R5, a certified diabetes educator with a private practice in Massape*ua, #.9., and author of The African American Guide to Living Well with Dia etes. G9our health care provider will give specific instructions based on the type of test and how your diabetes is managed.G Also, try to schedule your appointment as early as possible in the morning to prevent a longer fast, and bring food with you to eat as soon as the procedure is complete and you are cleared to eat.

Sta( Sa*e While Fasting With Dia%etes 6ltimately, whatever the reason, the most important advice is to fast smart. G7now the signs and symptoms of hyperglycemia and hypoglycemia,G says &rown-Riggs. G;top the fast immediately if blood glucose levels e'ceed J!! mgCdl or drop lower than B! mgCdl.G More ways to protect yourself while fasting?

:earn the appropriate treatment for low or high blood sugar, including use of glucose tablets, glucose gels, or glucagon in+ections. 5uring the fast, test your blood glucose levels more fre*uently. Dear a diabetes medical alert -5 bracelet.

7eep emergency contact information where others can find it.

)inally, don1t do anything without first consulting your doctor or diabetes educator. :ast 6pdated? 8!C!KC2!88

Diabetes Fasting and Non-Insulin Medications

9our doctor has suggested you have a test that re*uires you to fast before the test. This means you will not eat food or drin$ li*uids for a period of time before the test. -f you have diabetes and ta$e non-insulin medication this Test )acts will help you fast and control your blood sugar .glucose0 levels. -f, after reading this information you are still unsure as to how to dose your non-insulin medication, chec$ with the doctor who prescribes your non-insulin medication for advice.

"ire,tions for the Following /ills

Acarbose ')recose*( or Miglitol '+lyset*(, Stop taking on the day of fasting. Metformin '+lucophage*, +lucophage* S , or +lucovance*(, Stop taking on the day of fasting. Glyburide 'Dia#eta*, "icronase*, )res-abs*, +lynase*(, Stop taking on the day of fasting. Glipi ide '+lucotrol*(, Stop taking on the day of fasting. Glimipiride ' maryl*(, Stop taking on the day of fasting. Nateglinide 'Starlix*( or Repaglinide ')randin*(, Stop taking on the day of fasting. !ioglita one ' ctos*( or Rosiglita one ' vandia*(, Stop taking on the day of fasting. Sitagliptin '.anuvia*( or Sa"agliptin '/ngly0a*(, Stop taking on the day of fasting.

"ire,tions for the Following In0e,tion Shots

#"enatide '#yetta*(, Stop taking on the day of fasting. !ramlintide 'Symlin*(, Stop taking on the day of fasting.

Treating *ow #lood Sugar

hile Fasting

Dhile fasting, chec$ your blood sugar four times a day .at your usual mealtimes and at bedtime0 or anytime you have symptoms of a low blood sugar. 3ommon symptoms of a low blood sugar may include? sha$iness, diEEiness, sweating and headache. -f your blood sugar drops under B!, you should immediately ta$e 8K grams of glucose gel .8 tube0. This will usually raise your blood sugar by K! points in about 8K minutes. &e sure to re-chec$ your blood sugar 8K minutes after treatment, to ma$e sure it is over B!. -f not, ta$e a second tube of gel.

Treating !igh #lood Sugar

hile Fasting

-f your blood sugar stays over =!! for more than = hours, call the doctor who prescribes your insulin for advice.

"riving !ome After /ro,edures

5epending on the procedure #ational ewish Health may recommend a family member or friend drive you home. -f you drive home #ational ewish Health strongly recommends that you chec$ your blood sugar every time before driving a car. 9our blood sugar should be 8!! or higher before driving. 7eep fast-acting sugar with you in your car .glucose gel, glucose tablets or hard candy0. !e-e-%e$: -f your medication is not on this list or you still have *uestions, chec$ with the doctor who prescribes your medication for advice. &ring your glucose meter and test strips to #ational ewish Health on your test day.

!ow to Get to 'our /ro,edure

%n the day of your scheduled test, chec$ in at the )ront 5es$. -f you have *uestions before or during your test please call J!J-J,"-8JKK. Also, if you need to cancel the appointment or change the time please call. This information has een approved y Eli!a eth "#$# %ern& 'D& '( )(eptem er *+,+-#

"+asa Bagi "en&e$ita Dia%etes

&oleh$ah 5iabetisi . penderita 5iabetes atau 7encing Manis 0 berpuasa < 2ertanyaan ini $erap dia+u$an para penderita 5iabet men+elang &ulan Ramadan. awabnya boleh, bergantung $epada $ondisi fisi$ dan $adar /ula 5arah penderita. Tentu setelah ber$onsultasi $epada do$ter. 2enulis senga+a menempat$an 2edoman &erpuasa bagi penderita 5iabet di urutan pertama, dan menulisnya +auh hari sebelum &ulan Ramadan agar para penderita yang terbiasa berpuasa tida$ $ehilangan momen penting dalam pela$sanaan -badah 2uasa. ;elain itu, para penderita diharap$an dapat mempersiap$an diri dengan mengendali$an 7adar /ula 5arah, sehingga dapat berpuasa se$aligus men+aga $ondisi $esehatannya tetap prima. 5alam salah satu referensi disebut$an bahwa syarat diperboleh$annya berpuasa bagi 5iabetisi .penderita 5iabet0 +i$a $adar /ula 5arah ;ewa$tu atau 2 +am setelah ma$an tida$ melebihi 2K! mg L. Apabila $adar /ula 5arah ;ewa$tu atau 2 +am setelah ma$an lebih dari 2K! mg L, ma$a para 5iabetisi tida$ dian+ur$an berpuasa. &atasan 7adar /ula 5arah tida$lah terlalu mutla$. Hal yang lebih penting adalah $ondisi $esehatan dan fisi$ penderita. 6ntu$ menentu$an boleh tida$nya berpuasa, sebai$nya penderita 5iabet ber$onsultasi $epada do$ter yang telah terbiasa merawatnya. &eri$ut ini adalah beberapa tips yang perlu diperhati$an penderita 5iabet $eti$a mela$sana$an -badah 2uasa. ?? ?? ?? A5DA: MA7A# ?? ?? ?? 8. &u$a 2uasa ?

Ma$an ma$anan utama pertama Minum %bat Anti 5iabet pertama dan Mitamin, sebagai pengganti yang biasa diminum saat sarapan pagi pada saat tida$ berpuasa.

2. ;esudah sholat Tarawih atau 2 +am sesudah berbu$a puasa ? Ma$an ma$anan utama $edua %lahraga ringan .sesuai $emampuan0 J. ;ebelum Tidur Malam? Ma$an Ma$anan $ecil . snac$ 0 Minum %bat Anti 5iabet $edua, seperti yang biasa diminum siang hari saat tida$ berpuasa atau sesuai petun+u$ do$ter. =. Ma$an ;ahur ? Ma$an ma$anan utama $etiga .seperti ma$an malam saat tida$ berpuasa0 angan minum %bat Anti 5iabet saat ma$an sahur agar tida$ ter+adi hipoglo$emia .$e$urangan /ula 5arah0. K. ;ebelum -msa$ ? Ma$an ma$anan $ecil $edua . snac$ 0 Minum Mitamin $edua . atau sesuai petun+u$ do$ter 0

enis dan Ta$aran Ma$anan ? 2ada dasarnya, +enis dan ta$aran ma$anan saat berpuasa sama dengan pada saat tida$ berpuasa. ;edang$an dosis dan cara minum obat sesuai an+uran do$ter. ?? ?? ?? T - 2 ; ?? ?? ?? angan minum %bat Anti 5iabet pada saat ma$an sahur, $arena dapat menimbul$an hipogli$emia atau $e$urangan $adar gula darah pada saat be$er+a $eeso$an harinya. Apabila %bat Anti 5iabet diminum dua $ali, ma$a obat yang $edua diminum sesudah ma$an ma$anan $ecil sebelum tidur malam.

&ila ingin olahraga ringan, sebai$nya dila$sana$an sesudah ma$anan utama $edua yaitu sesudah sholat tarawih. 5aftar diit yang menyang$ut +enis dan ta$aran ma$anan, henda$nya meminta petun+u$ $epada do$ter yang merawat. Apabila ada hal-hal yang belum +elas sebai$nya bertanya $epada do$ter yang biasa merawat. Apabila 7adar /ula 5arah tinggi dan $ondisi badan lemah, sebai$nya tida$ usah mema$sa$an diri untu$ berpuasa. Apabila tida$ bisa berpuasa $arena penya$itnya, harap bertanya $epada ahli )i*ih tentang tatacara mengganti puasanya atau pembayaran )idyahnya.

;egala sesuatu ber$enaan dengan 5iabet selama penderita mela$sana$an ibadah puasa henda$nya ber$onsultasi $epada do$ter.

Diabetics must ta$e care %hen fasting

Manal -smail 56&A- CC The type of treatment a diabetic receives plays an important role in the way the body reacts during fasting, doctors have warned.

1stimates suggest that more than 23 per cent of "uslim -ype 4 diabetics in the 5 1 and Saudi rabia still choose to fast during %amadan, despite physicians6 concerns. +lobally, that number is nearly 73 per cent.

This change in eating patterns coupled with certain diabetes medication that stimulates insulin production can put diabetics at ris$, said 5r Alaa Fldin &ashier, an endocrinologist at 5ubai Hospital. There are three main forms of Type 2 diabetes treatment? metformin, which increases the body1s sensitivity to the insulin it produces4 sulfonylurea, which stimulates the pancreas to produce more insulin4 and sitagliptin, which also stimulates the pancreas to produce more insulin, but only when blood-sugar levels are high.

Metformin is usually prescribed to patients who show insulin resistance, in which case a combination of medication is sometimes used, 5r &ashier said. GThere is no point in stimulating insulin if the body does not react to it, so sometimes we use metformin with another drug,G he said on the sidelines of a conference on treatment options for diabetics last wee$. However, he warned that medications such as sulfonylureas, which induce insulin production regardless of blood-sugar levels, put patients at ris$ when they go without food for longs hours. He added that the drugs were still prescribed when the pancreas was e'hausted and producing very little insulin. Results from a clinical study last year by M;5, a 67-based pharmaceutical company that manufacturers sitagliptin, the generic for anuvia, showed that Muslims fasting during Ramadan who are ta$ing the medication run a lower ris$ of low blood pressure. More than 88,!!! Muslim Type 2 diabetics were as$ed to report incidents of symptomatic and asymptomatic low blood sugar during the study. Among all the patients, incidents of symptomatic low blood sugar fell from 8J per cent to B per cent, and incidents of asymptomatic hypoglycaemia fell from 8" per cent to , per cent. 56&A- CC The type of treatment a diabetic receives plays an important role in the way the body reacts during fasting, doctors have warned. Topic Fstimates suggest that more than ,! per cent of Muslim Type 2 diabetics in the 6AF and ;audi Arabia still choose to fast during Ramadan, despite physicians1 concerns. /lobally, that number is nearly "! per cent. This change in eating patterns coupled with certain diabetes medication that stimulates insulin production can put diabetics at ris$, said 5r Alaa Fldin &ashier, an endocrinologist at 5ubai Hospital. There are three main forms of Type 2 diabetes treatment? metformin, which increases the body1s sensitivity to the insulin it produces4 sulfonylurea, which stimulates the pancreas to produce more insulin4 and sitagliptin, which also stimulates the pancreas to produce more insulin, but only when blood-sugar levels are high. Metformin is usually prescribed to patients who show insulin resistance, in which case a combination of medication is sometimes used, 5r &ashier said. GThere is no point in stimulating insulin if the body does not react to it, so sometimes we use metformin with another drug,G he said on the sidelines of a conference on treatment options for diabetics last wee$. However, he warned that medications such as sulfonylureas, which induce insulin production regardless of blood-sugar levels, put patients at ris$ when they go without food for longs

hours. He added that the drugs were still prescribed when the pancreas was e'hausted and producing very little insulin. Results from a clinical study last year by M;5, a 67-based pharmaceutical company that manufacturers sitagliptin, the generic for anuvia, showed that Muslims fasting during Ramadan who are ta$ing the medication run a lower ris$ of low blood pressure. More than 88,!!! Muslim Type 2 diabetics were as$ed to report incidents of symptomatic and asymptomatic low blood sugar during the study. Among all the patients, incidents of symptomatic low blood sugar fell from 8J per cent to B per cent, and incidents of asymptomatic hypoglycaemia fell from 8" per cent to , per cent. 5r Harvey 7atEeff, global director for scientific affairs at M;5, said dehydration during Ramadan could also lower blood sugar, leaving patients with an Ginto'icatedG feeling. GThey may feel confused, wea$ and disorientated,G he said. GThis is particularly concerning for patients when they are driving or operating heavy e*uipment.G The American 5iabetes Association recommends that people with Type 2 diabetes wishing to fast during Ramadan undergo a medical assessment one to two months in advance. 5espite the availability of new medications, many patients still choose traditional forms because of cost. ;ulfonylureas, which have been around for decades, cost between 5hK! and 5h,! for a onemonth supply, while sitagliptin, which has only been available for about three years, costs more than four times that, between 5h2"! and 5hJ!!. -nsurance coverage varies. Meanwhile, those with Type 8 diabetes have limited options, 5r &ashier said. GThese are people who do not produce insulin at all, and their only choice is direct in+ection of insulin into the body,G he said. GThis ma$es it difficult to control the way a patient reacts during Ramadan.G mismailNthenational.ae