Your Ramadan Fast

Ramadan is a blessed month in the Muslim calendar. It is obligatory for Muslims to observe fast this month. Every year, I spend several weeks before Ramadan counseling my patients about the safety of their fasting and any special precautions they need in diet, medication, and lifestyle to observe the fast.

Here are some frequently asked health questions about fasting during the holy month of Ramadan. I have attempted to answer these questions based on Quranic verses, Hadith, Shariyah, and evidence-based medical literature.

Doctor, I regularly fast during Ramadan. Could you give me advice on my diet?

To remain healthy during Ramadan, regular quantities of food from the major food groups (bread and cereal, milk and dairy products, fish, meat and poultry, beans, vegetables, and fruit) should be consumed. Fruit intake after a meal is strongly suggested. High-fiber diets have an excellent effect on our satiety and are most suited for Ramadan.

Given the long hours of fasting, we should consume the so-called ‘complex carbohydrates’ or slow-digesting foods at Suhoor so that the food lasts longer (about 8 hours) and makes us less hungry during the day. Such foods include grains and seeds, namely barley, wheat, oats, millet, semolina, beans, lentils, whole-meal flour, and unpolished rice. In addition, I can take skinless chicken, fish, low-fat dairy products, fresh vegetables, and fruits.

In contrast, Iftar is the time to replenish energy, and every effort should be made to consume foods from all major food groups: fruit and vegetables, rice, whole meal bread, lean meat, skinless chicken, fish, eggs, legumes, and low-fat dairy products. Dates are an excellent source of sugar, fiber, carbohydrates, potassium, and magnesium. They have been recommended since the days of the Prophet Muhammad (PBUH) as a good way of breaking the fast. Fried foods, very spicy foods, and foods containing too much sugar, such as sweets, can cause health problems and should be limited during Ramadan. They cause indigestion, heartburn, and weight problems.

Doctor, who are those exempt from the Ramadan Fast?

Several groups are exempt from fasting during Ramadan, including:

• Prepubertal children: Children who are not yet at puberty are not required to fast.
• Menstruating women: Women who are menstruating or experiencing postnatal bleeding are exempt from fasting.
• Pregnant or breastfeeding women: Women who are pregnant or breastfeeding are exempt from fasting if they believe it may harm them or their baby.
• The elderly: The elderly who cannot tolerate fasting are exempt.
• The mentally disabled: People with mental disabilities are exempt from fasting.
• The sick: People who are ill and fasting would aggravate their condition are exempt from fasting.
• Travelers: People who are traveling and intend to spend more than five days away fro home or travel more than 50 miles are exempt from fasting.
• People fighting a battle in the cause of Allah (SWT): People fighting a battle in the cause of Allah (SWT) are exempt from fasting.
• People under compulsion: People under compulsion are exempt from fasting.

When can the missed fast be made up?

If someone can make up for a missed fast later, they should do so. However, if they cannot, they should pay Fidya. Fidya is a religious donation of money or food made by Muslims who cannot fast during Ramadan.

Doctor, I am 8 years old. Am I allowed to fast?

Children are required to fast from puberty. Fasting before this age is tolerated differently depending on the child’s general health, nutrition, and attitude. Fasting under the age of eight isn’t advisable. It is a good idea to make children aware of fasting and practice fasting for a few hours.

Doctor, what is your advice to pregnant mothers about Ramadan Fast?

Medical evidence suggests that fasting during pregnancy is not a good idea. However, if a pregnant woman feels strongly about fasting, she may fast, especially during the early pregnancy. If she doesn’t feel well enough, Islamic law gives her explicit permission not to fast and to make up for the missed fasts later or pay Fidya.

Doctor, what is your advice to breastfeeding mothers?

Islamic law says breastfeeding mothers do not have to fast. Missed fasting must be compensated for later or by paying fidya.

Is Ramadan a good time to quit smoking?

Yes. Smoking is wasteful and seriously bad for your health. Ramadan is an excellent opportunity to change many unhealthy habits, and smoking is one of them.

Doctor, I love swimming. Can I swim during the fast period?

Yes, but do not drink the water. A bath, shower, or swimming does not affect the fast. However, no water should be swallowed during these activities as that would break the fast.

Doctor, I felt dehydrated during the fast. Am I allowed to break the fast?

You could have harmful levels of water loss if you were poorly hydrated (not drinking enough) before the fast. Poor hydration can be made worse by weather conditions and even everyday activities like walking or housework. If you produce very little or no urine, feel disorientated and confused, or faint due to dehydration, you must stop fasting and drink water or other fluids. Islam doesn’t require you to harm yourself in fulfilling the fast.

Doctor, I suffer from Thalassemia and need regular blood transfusions. Can I receive blood transfusions during fasting?

No. A person receiving a blood transfusion is advised not to fast on medical grounds. They may fast on the days when no transfusions are required.

Doctor, I need to take my tablets every 6 hours. Can I take tablets during the fast?

If the medicine needs to be taken during fasting, do not fast. If this medication is required to treat a short illness, you can compensate for missed fasts by fasting on other days when you are well. If you are on long-term medication, then you could talk to your doctor about whether to change your medication so that you can take it outside the time of the fast. If your disease is unstable or poorly controlled, do not fast. Those who cannot do the missed fasts later due to the long-term use of medication should do fidya.

Doctor, I suffer from gas and bloating and have been told to suffer from irritable bowel. Can I fast?

Patients with gas, irritable bowel syndrome, altered bowel habits, and dyspepsia (presenting as bloating or indigestion) can be allowed to fast safely, and symptoms in many such patients regress during the fast period. However, patients with chronic eventful illnesses like ulcerative colitis or Crohn’s disease should not fast while the disease is on active medication and remission is yet to occur.

Doctor, I suffer from acidity and heartburn and need acid-reducing tablets daily. Can I fast?

Heartburn, a symptom of acid reflux in the food pipe, may worsen during fasting, and advice on such patients can be individualized. Many such patients may fast with no problem if symptoms are controlled with an acid-reducing pill taken once a day.

Doctor, I have suffered from black motion due to an ulcer in the stomach. Can I fast?

Patients with active ulcer disease cannot fast till the ulcer heals and any precipitating cause of ulcer-like Helicobacter pylori infection is eradicated, or ulcerogenic drugs are withdrawn. Patients with silent ulcers or those who have had bleeds from ulcers should not fast as fast may precipitate bleeding or cause ulcer perforation. Some physicians believe that patients with peptic ulcer disease can fast as fast, which may improve their symptoms and promote ulcer healing. This concept is wrong. There is a definite increase in the severity of symptoms in patients with peptic ulcer disease, and many may come up with bleeding and perforation during and soon after Ramadan fast. Studies on volunteers and peptic ulcer patients have shown a definite increase in acid and hormone Gastrin (which produces acid from the stomach) during a fast, which persists for a month or more after the fast. Thus, patients with active and symptomatic peptic ulcers and those who have had difficult ulcers and/or have bled in the past should not fast on medical grounds.

Doctor, I have a fatty liver and want to fast. Can I fast with safety?

Patients with non-alcoholic fatty liver (NAFLD) can safely fast, and even Ramadan fasting may be beneficial to control weight and dyslipidemia. Patients with chronic liver diseases that are stable impose no added risk with fasting. However, chronic liver disease, which shows signs of liver failure, may worsen with fasting, and such patients need advice accordingly.

Doctor, I suffer from migraine and need frequent medication to control my headaches. Can I fast?

Migraine is a common occurrence in every community, and around 12 percent of adults suffer from various clinical manifestations of migraine. Ramadan fast has the potential to cause exacerbations of headaches, mainly related to dehydration and caffeine withdrawal. Physicians should consider prophylactic drug therapy to reduce the frequency and severity of attacks if migraine patients are particular to undertake fast. People with uncontrolled, frequently occurring migraine or cluster headaches should not fast as fasting may worsen migraine and interfere with managing acute attacks. However, if migraines are well controlled and attacks are infrequent, fast treatment may be allowed under supervision.

Doctor, I suffer from high blood pressure. Can I fast?

Patients suffering from mild to moderate high blood pressure should be encouraged to fast as it may help control blood pressure. It is advisable to use sustained-release drug formulations whose effect can last through the fasting period. Diuretics which may cause dehydration need to be used with caution. Patients with stable heart disease, including ischemic heart disease, can safely fast if drug dosage can be rescheduled to last over the fasting period. Patients with severe uncontrolled hypertension, unstable heart disease, or those who have complications like renal failure, recent stroke, or heart failure should be advised against fasting; as such, patients need active life-saving treatment, and fasting can impede disease recovery and adversely influence disease.

Doctor, I suffer from asthma and need inhalers to control my asthma. Can I fast and use inhalers during fast?

Muslim experts differ on this issue. Some say using an asthma inhaler isn’t the same as eating or drinking and is permitted during fasting. In their view, people with asthma can fast and use their inhalers whenever needed. However, other scholars say that the inhaler provides small amounts of liquid medicine to the lungs, so it breaks the fast. They say people with poor asthma control must not fast until reasonable control is achieved. Some people with asthma may opt for longer-acting inhalers and fast.

Doctor, I am a diabetic. Can I fast?

I employ specific criteria to advise my patients regarding the safety of the Ramadan fast.

Ramadan fasting is not recommended for diabetics under the following conditions:

1. All brittle type I diabetic patients (on Insulin therapy).
2. Poorly controlled type I or type II diabetic patients (markedly elevated blood glucose values or HbA1C above 12 percent).
3. Diabetic patients not compliant with diet/drug regimens and daily activity.
4. Diabetic patients with severe complications such as unstable angina or uncontrolled hypertension.
5. Patients with a history of diabetic ketoacidosis.
6. Pregnant diabetic patients.
7. Diabetic patients with inter-current infections.
8. Elderly diabetic patients with any degree of alertness problems.
9. Diabetics with two or more episodes of hypoglycemia and/or hyperglycemia during the Ramadan fast.

I advise Ramadan fast in all other diabetic patients and encourage Ramadan fast in those under the following conditions:

• Diabetics who are overweight (BMI greater than 28).
• Diabetics who are on anti-diabetic pills or diet advice alone (except pregnant or nursing mothers),
• Diabetics with stable metabolic control (HBAIC less than 7%).

Doctor, I am a diabetic and am fasting during Ramadan. Can I check my finger-stick blood sugar test during the fasting period?

Many ethical questions from fasting Muslim patients include:

1. Can we have finger-stick blood drawn for blood sugar? (Answer-yes).
2. Can we use mouthwash during fasting? (Answer-yes).
3. Can we take medicine during fasting? (Tablet-no, patch-yes, inhaler-yes, injection-no).
4. When should a diabetic break his fast before Iftar? (When blood glucose is less than 60 or over 400).

Doctor, I am a diabetic and controlled with diet alone. Can I fast?

People whose diabetes is controlled with diet and physical activity should be able to fast safely.

However, food and drink at Suhoor should be carefully thought out, with low-calorie beverages and a limited intake of sweets and fried foods.

Doctor, I am a diabetic and take tablets to control my sugar. Can I fast?

During Ramadan, diabetics may need to adjust their oral antidiabetic medications to manage their blood sugar levels while fasting. The goal is to minimize the risk of hypoglycemia and hyperglycemia.

• Oral antidiabetics with a low risk of hypoglycemia include Biguanides (metformin), Thiazolidinediones (pioglitazone, rosiglitazone), Alpha-glucosidase inhibitors (acarbose, miglitol), Dipeptidyl peptidase-4 (DPP-4) inhibitors (sitagliptin, saxagliptin, vildagliptin), and Sodium-glucose cotransporter 2 (SGLT2) inhibitors (canagliflozin, dapagliflozin, empagliflozin). Drugs with a high risk of hypoglycemia include Sulfonylureas (e.g., glyburide, glipizide, glimepiride) and Meglitinides (repaglinide, nateglinide).

• Diabetics on Biguanides (Metformin) can be allowed to fast because this drug does not significantly drop blood glucose below the normal range. Two-thirds of the drug should be given immediately at Iftar and one-third at Suhoor. If the patient feels unwell on metformin, it is worth considering lowering the drug dose or even stopping the drug for the duration of the fast.
• Patients on Thiazolidinediones (Rosiglitazone and Pioglitazone) do not cause hypoglycemia; hence, no change in dose administration or dosage is required. These drugs are taken with or without food at the same time each day, so the dosage should not be affected.
• Insulin secretagogues include first-generation sulfonylureas (Chlorpropamide, Tolazamide, and Tolbutamide), second-generation sulfonylureas (Glimepiride, Glipizide, and Glyburide) and Non-sulfonylureas (Repaglinide and Nateglinide). First-generation sulfonylureas are similar in potency to second-generation agents but have a longer half- life (24 to >48 hours versus 12 to 18 hours), a greater incidence of hypoglycemia, and more frequent drug interactions. Thus, it is advisable to avoid first-generation sulfonylureas during Ramadan fast, and if needed, second-generation sulfonylureas are generally preferred. Repaglinide and nateglinide have the potential to cause hypoglycemia but have shorter half-lives (2 to 6 hours), can be given with each meal or immediately before to reduce meal-related glucose excursions, and are well suited for patients during the Ramadan fast.
• DPP-4 inhibitors, SGLT2 inhibitors, and Alpha-glucosidase inhibitors are associated with a lower risk of hypoglycemia and can be used safely during Ramadan.

Doctor, I am on Insulin and want to fast. What is your advice on Insulin therapy?

Diabetics who are on Insulin need to readjust their insulin therapy by the treating physician. Generally, Insulin can be adjusted as a three-dose regimen (two doses of regular short-acting insulin at/before Suhoor and Iftar and one dose of intermediate-acting insulin in the late evening) or a two-dose regimen (regular short-acting insulin at Suhoor and combined/premixed short/medium-acting insulin at Iftar). Insulin prandial analogs (Lispro and Novo-Rapid) are also helpful and can be administered at Iftar and give a lower risk of hypoglycemia during the night. These have been shown to help control glycemic levels during Ramadan compared to regular human insulin. Pre-mixed/combined short/medium-acting insulin should not be used at Suhoor to avoid late afternoon hypoglycemia. Home blood glucose monitoring should be performed just before the Iftar (sunset meal) and three hours afterward. It should also be performed before the Suhoor (pre-dawn meal) to adjust the insulin dose and prevent hypoglycemia and post-prandial hyperglycemia following over-eating.

Doctor, what is your advice on fasting to patients on dialysis?

Hemodialysis, performed about three times a week, causes significant shifts of fluids and salts within the body. People on peritoneal dialysis must not fast and should perform Fidya.

(The Author is MD, DM, FRCP (Edin), FACP, Master American College of Physicians (MACP, Emeritus). Former Dean & Director SKIMS and Ex-officio Secretary to Govt. Former Professor & Head of Gastroenterology and Chairman of Dept. Medicine, SKIMS. Former Consultant & Head of Gastroenterology and Liver Transplantation, KFSH & RC, Riyadh. Director, Digestive Diseases Centre, Dr. Khuroo’s Medical Clinic, Srinagar. E-mail: [email protected]. [email protected], Website: www.drkhuroo.in, Facebook: www.facebook.com/mohammad.khuroo, Twitter: Mohammad Khuroo @mskhuroo, YouTube: Dr. Khuroo’s Medical Channel https://www.youtube.com/@drkhuroo)