The diabetic patient and fasting
Question

My mother has diabetes, and she uses insulin injections, but she insists on fasting in Ramadan with us; however, there are some days when she is not able to fast, so she breaks the fast. But after the end of the month, the total number of days that she did not fast was four days, but she is not able to make up these days because it is too hard, but at the same time she will almost certainly fast with us next Ramadan, in sha Allah, and she will not fast on some days of the month because it is too difficult. In this case, does she have to make up the missed fasts or should she pay the fidyah?
Praise be to Allah.It is permissible for the sick person for whom it is difficult to fast because of sickness to break the fast during Ramadan.
Allah, may He be exalted, says (interpretation of the meaning):
{So whoever sights [the new moon of] the month, let him fast it; and whoever is ill or on a journey – then an equal number of other days. Allah intends for you ease and does not intend for you hardship}
[al-Baqarah 2:185].
Ibn Kathir (may Allah have mercy on him) said:
The words { and whoever is ill or on a journey – then an equal number of other days} mean: and whoever is suffering from physical illness that makes it hard for him to fast, or fating will harm him, or he on a journey, i.e. whilst he is travelling, then he may break the fast. But if he breaks the fast, then he must make up the number of days that he did not fast whilst travelling. Hence Allah says: {Allah intends for you ease and does not intend for you hardship}. In other words, He has granted you a concession allowing you not to fast in the case of illness or travel, when fasting is a must for the one who is at home and is healthy, so as to make it easy for you and out of mercy towards you.
End quote from Tafsir Ibn Kathir (1/503).
Al-Qurtubi (may Allah have mercy on him) said:
With regard to the word {ill}, there are two scenarios for the one who is ill:
In the first scenario, the ill person cannot fast at all, in which case breaking the fast is obligatory for him.
In the second scenario, he is able to fast, but it will harm him and cause him hardship. In this case it is recommended (mustahabb) for him not to fast, and no one would fast in this case except one who is ignorant.
End quote from Tafsir al-Qurtubi (3/127).
Shaykh Ibn ‘Uthaymin (may Allah have mercy on him) said:
There are several scenarios for the one who is ill:
In the first scenario, he will not be affected by fasting, such as one who has a mild cold, a mild headache or a mild toothache, and the like. In this case, it is not permissible for him to break the fast, even though some of the scholars said that it is permissible for him to do so, because of the general meaning of the words {and whoever is ill}. But we say: this ruling is based on a condition, which is that breaking the fast is more appropriate and will help to ease his pain. In that case, we say that he may break the fast. But if it will not make any difference, then it is not permissible for him to break the fast, and he must fast.
In the second scenario, if fasting will cause him hardship but will not harm him, then it is disliked (makruh) for him to fast and it is Sunnah for him to break the fast.
In the third scenario, if fasting will cause him hardship and will harm him, such as a man who has kidney disease or diabetes and the like, then fasting is forbidden (haram) in his case.
… Thus we know that the decision of some sick people, for whom fasting is difficult and may harm them, yet they refuse to break the fast, is wrong. Therefore we say: these people are mistaken when they do not want to accept the generosity of Allah, may He be glorified and exalted, and they do not accept His concession, thus harming themselves, when Allah, may He be glorified and exalted, says (interpretation of the meaning): {And do not kill yourselves} [an-Nisa’ 4:29].
End quote from ash-Sharh al-Mumti‘ (6/341-342).
Secondly:
Based on the above, diabetes is of different types, and the scenarios faced by diabetics vary with regard to how severely fasting may harm them and how difficult it may be for them. Some of them may be harmed by it and find it difficult, whilst others will not be harmed by it and will not find it extraordinarily difficult; rather it may benefit them.
The International Islamic Fiqh Council, in cooperation with the Islamic Organization for Medical Sciences, undertook a study of cases of diabetic patients, and concluded that such patients may be divided into four groups in terms of how fasting may be harmful to them. In Statement no. 183 (9/19), Regarding diabetes and fasting, it says:
The session of the International Islamic Fiqh Council, in conjunction with the Organisation of the Islamic Conference, that was held during its nineteenth session…
Based on the cooperation between the Islamic Organization for Medical Sciences and the International Islamic Fiqh Council, which was based on an agreement signed by the two organizations, and after the fiqh council commissioned the medical organization to carry out a study on diabetes and the Ramadan fast,
based on the two symposia that were held by the medical organization…
And after studying the research that was presented to the fiqh council upon the completion of the research on diabetes and fasting, and after listening to the discussion that took place on the topic,
and after discussing the medical and juristic perspectives on the effect of fasting on diabetic patients,
they determined the following:…
Thirdly: classifying diabetic patients according to medical criteria:
According to medical criteria, diabetics may be divided into four groups in the following manner:
The first group:
Patients for whom there is a great likelihood of serious complications, in such a way that is confirmed by medical studies, and their medical status is distinguished by one or more of the following:

Extreme drop in blood sugar levels during the three months prior to Ramadan.
Patients whose blood sugar levels repeatedly fluctuate.
[Asymptomatic] patients who are not aware when their blood sugar level drops. This is something that happens to some diabetics, especially those who have Type I diabetes, whose blood sugar level may frequently drop greatly for long periods of time.
Patients who are known to find it difficult to control their blood sugar for long periods.
Frequent occurrence of diabetic ketoacidosis or fainting during the three months prior to Ramadan.
Type I diabetes.
Extreme sickness from co-morbidities.
Diabetics who are compelled to do hard physical labour.
Diabetics who undergo kidney dialysis.
Women affected by gestational diabetes.

The second group:
Patients who are at a relatively high risk of complications as a result of fasting, which the doctors think will most likely happen. Their case may involve one or more of the following:

Those who suffer high blood sugar levels, such as when the average is 180-300 milligrams per deciliter (mg/dL) or 10-16.5 millimoles per liter (mmol/L), and the rate of accumulated glycated haemoglobin is above 10%.
Those suffering from kidney failure.
Those suffering from problems with their arteries, such as heart disease and arterial disease.
Those who live alone and are treated by insulin injections or drugs that lower blood sugar levels by stimulating insulin-producing cells in the pancreas.
Those who suffer other diseases that increase their risks.
Elderly patients who are affected by other diseases.
Patients who receive treatments that affect their cognitive functioning.

End quote.
They stated that the ruling on these two groups is to be based on ascertaining that there will be extreme harm, or it is thought most likely that that will happen, according to what the specialist doctor thinks. In that case it becomes obligatory, according to Islamic teachings, for the patient to whom one of the scenarios mentioned regarding these two groups applies, to break the fast, and it is not permissible for him to fast, so as to ward off harm from himself, because Allah, may He be exalted, says (interpretation of the meaning):
{and do not throw [yourselves] with your [own] hands into destruction}
[al-Baqarah 2:195]
{And do not kill yourselves. Indeed, Allah is to you ever Merciful}
[an-Nisa’ 4:29].
The rulings on breaking the fast in Ramadan because of sickness apply to those in the first and second groups, in accordance with the words of Allah (interpretation of the meaning):
{So whoever among you is ill or on a journey [during them] – then an equal number of days [are to be made up]. And upon those who are able [to fast, but with hardship] – a ransom [as substitute] of feeding a poor person [each day]}
[al-Baqarah 2:184].
The one who fasts when he will be harmed by fasting is sinning, although his fast is valid. End quote.
As for the third group:
This includes patients for whom there is moderate risk of being exposed to complications as a result of fasting. This includes diabetic patients who are stable and their blood sugar is under control through use of appropriate medication which lowers blood sugar by stimulating insulin-producing cells in the pancreas.
The fourth group:
This includes patients for whom there is a low risk of being exposed to complications as a result of fasting. This includes patients who are stable and their blood sugar is under control through diet alone, or through taking medicines that reduce the blood sugar without stimulating insulin-producing cells in the pancreas; rather this medication increases the effectiveness of the insulin that they have. End quote.
Thus they reached the following conclusion:
It is not permissible for patients of these two groups to break the fast, because the medical information does not indicate any possibility of complications that could affect their health or pose a risk to their life; rather many of them may benefit from fasting.
End quote from Majallat al-Majma‘ al-Fiqhi al-Islami (19/4/1225-1229).
Based on that, your mother should consult a trustworthy specialist doctor. If it becomes clear that she belongs to the first or second groups, then she does not have to fast during Ramadan or at other times, and you should advise her not to fast and not to harm herself.
As this disease is chronic, what she should do is feed the poor instead of fasting, and she does not have to make up the fasts. Allah, may He be exalted, says (interpretation of the meaning):
{And upon those who are able [to fast, but with hardship] – a ransom [as substitute] of feeding a poor person [each day]}
[al-Baqarah 2:184].
Shaykh ‘Abd ar-Rahman as-Sa‘di (may Allah have mercy on him) said:
The words { And upon those who are able [to fast, but with hardship] } that is, they are able to fast, but with difficulty
{a ransom [as substitute]} to compensate for each day they did not fast
{of feeding a poor person [each day]} …
It was also stated that the phrase { And upon those who are able [to fast, but with hardship] } refers to those who found it burdensome and unbearably difficult, such as the elderly; they could compensate by feeding one poor person for each day they did not fast. This is the correct view. End quote.
Shaykh Ibn ‘Uthaymin (may Allah have mercy on him) said:
We must understand that those who are sick may be divided into two categories:
… The second category is patients who are suffering chronic diseases, such as cancer – Allah forbid – kidney disease, diabetes and other chronic illnesses for which there is no hope of the patient recovering. In these cases, the sick person may break the fast in Ramadan, but he must feed one poor person for each day. This applies to people such as elderly men and women who cannot fast; they should break the fast and feed one poor person for each day. The evidence for that from the Qur’an is the verse in which Allah, may He be exalted, says (interpretation of the meaning):
{And upon those who are able [to fast, but with hardship] – a ransom [as substitute] of feeding a poor person [each day]}
[al-Baqarah 2:184].
Allah, may He be exalted, has made feeding the poor an alternative to fasting. There was a choice between the two options in the beginning, then fasting was made obligatory, after which if a person was unable to fast either at the time of Ramadan or afterwards, then he moved to the alternative, which Allah has made an alternative to fasting, namely feeding the poor.
Thus it is obligatory for those suffering chronic diseases and the elderly, male or female, if they are unable to fast, to feed one poor person for each day, which may be done by giving food to the poor, or inviting a number of poor people equal to the number of days, and giving them dinner, as Anas ibn Malik (may Allah be pleased with him) used to do. When he grew old, he would gather thirty poor persons and give them dinner, and that was an alternative to fasting the month.
End quote from Majmu‘ Fatawa ash-Shaykh Ibn ‘Uthaymin (19/111-112).
For more information, please see the answer to question no. 49944.
But if your mother is one of the third or fourth groups, then she must make up the fasts as much is she is able, even if she spreads them throughout the year, and she may choose days when it is not difficult to fast, such as winter days.
And Allah knows best.