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Doctor, I want to fast this Ramadhan! But I have a question?

PROF. MOHAMMAD SULTAN KHUROO

 Ramadan is the blessed month in the Muslim calendar. It is obligatory on Muslims to fast in this month. Fasting is not meant to create excessive hardships to the Muslims. The Quran specifically exempts the sick individual from fasting; especially if fasting can lead to harmful consequences. Fasting for extended periods for one month can cause health issues in patients with number of medical illnesses and there are clear instructions for us as doctors to pass these to our patients.  Every year I spend several weeks prior to Ramadan in counselling my patient’s about the safety of their observance of fast and any special precaution they need in diet, medication and life style to observe 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, Shariah and evidence based medical literature. 

Doctor, I regularly fast during Ramadan. Give me advice on my diet?
To remain healthy during Ramadan, normal quantities of food from the major food groups (bread and cereal, milk and dairy product, fish, meat and poultry, bean, vegetable and fruit) should be consumed. Intake of fruits after a meal is strongly suggested in view of the long hours of fasting, we should consume the so-called ‘complex carbohydrates’ or slow digesting foods at Sahoor so that the food lasts longer (about 8 hours) making you less hungry during the day.  In contrast, refined carbohydrates or fast-digesting foods last for only 3 to 4 hours and may be better taken at Iftaar to rapidly restore blood glucose levels  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.  High fiber diets have an excellent effect on our satiety and most suited for Ramadan.

Doctor, who are those exempt from Ramadan Fast?
Dear, you shall be exempted from Ramadan Fasting under following conditions: Children, the sick, older people and the infirm, people experiencing short-term/long-term mental health concerns, people with learning disabilities and anyone who would be putting their health at serious risk by fasting. There are also certain circumstances where people normally able to fast are unable to, such as when people are on a tiring journey or if a woman is pregnant or on her period, and in these instances the person is asked to make up the fast at a later date, or perform Fidya.

Doctor, I am a diabetic. Can I fast?
Physicians working with Muslim diabetics should employ certain criteria to advise their patients regarding the safety of Ramadan fast. It is believed that fast should be forbidden in diabetics under following conditions:
(i). All brittle type I diabetic patients (on Insulin therapy),
(ii). Poorly controlled type I or type II diabetic patients (markedly elevated blood glucose values or HbA1C above 12 percent),
(iii). Diabetic patients known to be not compliant on diet/drug regimens and daily activity,
(iv).  Diabetic patients with serious complications such as unstable angina or uncontrolled hypertension;
(v).  Patients with a history of diabetic ketoacidosis,
(vi). Pregnant diabetic patients,
(vii). Diabetic patients with inter-current infections,
(viii). Elderly patients with any degree of alertness problems,
(ix). Diabetics with two or more episodes of hypoglycaemia and/or hyperglycemia during Ramadan fast.

Fasting should be encouraged in diabetics under following conditions:
(i). Diabetics who are overweight (weight levels 20% above the ideal weight or body mass index [body weight, kg/height, meters squared] greater than 28),
(ii).  Diabetics who are on anti-diabetic pills or diet advice alone (except pregnant or nursing mothers),
(iii). Diabetics with stable metabolic control (HBAIC less than 6%).

Doctor, I am on Insulin and want to fast. What is your advice on Insulin therapy?
If a diabetic who is on insulin therapy chooses to observe fast, insulin therapy needs to be readjusted either as three-dose insulin regimen (two doses of regular short-acting insulin at/before Sahoor and Iftaar and one dose of intermediate-acting insulin in the late evening) or two- dose insulin regimen (regular short acting insulin at Sahoor and combined/premixed short/medium-acting insulin at Iftaar). Insulin prandial analogues (Lispro and Novo-Rapid) are also useful and can be administered at Iftaar and give a lower risk of hypoglycaemia during the night. These have been shown to help with glycemic control during Ramadan compared with regular human insulin. Pre-mixed/combined short/medium acting insulin should not be used at Sahoor to avoid late afternoon hypoglucemia. Home blood glucose monitoring should be performed just before the Iftaar (sunset meal) and three hours afterwards. It should also be performed before the Sahoor (pre-dawn meal) to adjust the insulin dose and prevent any hypoglycaemia and post-prandial hyperglycemia following over-eating.

Doctor, I am a diabetic and controlled with diet alone. Can I fast?
People whose diabetes is controlled by diet and physical activity alone should be able to fast safely. However, food and drink at Sahoor should be carefully thought out, using low-calorie drinks and limiting intake of sweets and fried foods.

Doctor, I am a diabetic and take tablets to control my sugar. Can I fast?
Diabetics who are on Biguanides (Metformin) can be allowed fast safely, because this drug does not cause significant drop in blood glucose to below normal range. Two third of the drug should be given immediately at Iftaar and one-third at Sahoor. It is worth considering to lower drug dose or even stopping the drug for duration of fast if the patient feels unwell on metformin. Patients on Thiazolidinediones (Rosiglitazone and Pioglitazone) do not cause hypoglycaemia hence no change in dose administration or dosage is required. These drugs taken with or without food at the same time each day dosage should not be affected. Insulin secretagogues include first (Chlorpropamide, Tolazamide and Tolbutamide), second (Glimepiride, Glipizide and Glyburide) generation sulfonylureas 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 second-generation sulfonylureas are generally preferred.  Repaglinide and nateglinide have shorter half-life (2 to 6 hours), are given with each meal or immediately before to reduce meal-related glucose excursions and are ideally suited for patients during Ramadan fast.

Doctor, I am a diabetic and am fasting during Ramadan. Can I check my finger-stick blood sugar test during fasting period?
Many ethical questions from fasting Muslim patients include:
(i). Can we have finger-stick blood drawn for blood sugar? (Answer-yes)
(ii).  Can we use mouthwash during fasting? (Answer-yes)
(iii).  Can we take medicine during fasting? (Tablet-no, patch-yes, inhaler-yes, injection-no),
(iv). When should a diabetic break his fast before Iftaar? (When blood glucose is less than 60 or over 400).

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 adults suffer from various clinical manifestations of migraine. Ramadan fast has potential to cause exacerbations of headaches, mainly related to dehydration and caffeine withdrawal.   Physicians should consider prophylactic drug therapy to reduce 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 in managing acute attacks. However, if migraine is well controlled and attacks are infrequent fast 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 of 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 forbidden from fasting as such patients need active life saving treatment and fasting can impede disease recovery and influence adversely disease outcome.

Doctor, what is your advice to pregnant women about Ramadan Fast?
There’s medical evidence to show that fasting in pregnancy is not a good idea. If a pregnant woman feels strong and healthy enough to fast, especially during the early part of the pregnancy, she may do so. If she doesn’t feel well enough to fast, Islamic law gives her clear permission not to fast, and to make up the missed fasts later. If she is unable to do this,she must perform fidyah (a method of compensation for a missed act of worship).

Is Ramadan a good time to quit smoking?
Yes. Smoking is wasteful and seriously bad for your health. Ramadan is a great opportunity to change many unhealthy habits, and smoking is definitely one of them.

Doctor, I am 8 years old. Am I allowed to fast?
Children are required to fast from the age of puberty. It isn’t harmful. Fasting before this age is tolerated differently depending on the child’s general health, nutrition and attitude.  Fasting under the age of seven or eight isn’t advisable. It is a good idea to make children aware of the practice of fasting and to practise fasting for a few hours at a time.

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

Doctor, I love swimming. Can I swim during fast period?
Yes, but do not drink the water. A bath or shower or swimming has no effect on the fast. But no water should be swallowed during any of these activities as that would break 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 tables every 6 hours. Can I take tables during fast?
If the medicine needs to be taken during fasting, do not fast. If this medication is required as treatment for 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 GP 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 are unable to do the missed fasts later, due to the long-term use of medication, should do fidyah.

Doctor, what is your advice to breastfeeding mothers?
No. Islamic law says a breastfeeding mother does not have to fast. Missed fasts must be compensated for by fasting or fidyah once breastfeeding has stopped.

Doctor, I felt dehydrated during fast. Am I allowed to break the fast?
Yes. You could have harmful levels of water loss if you were poorly hydrated (not drinking enough water) before the fast. Poor hydration can be made worse by weather conditions, and even everyday activities like walking to walk or housework. If you produce very little or no urine, feel disorientated and confused, or faint due to dehydration, you must stop fasting and have a drink of water or other fluid. Islam doesn’t require you harm yourself in fulfilling the fast. If a fast is broken, it will need to be compensated for by fasting at a later date.

Doctor, what is your advice on fasting to patients on dialysis?
People on peritoneal dialysis must not fast and should perform Fidya. Haemodialysis is performed about three times a week, and causes significant shifts of fluids and salts within the body. Such patients must not fast and should perform Fidya.

Doctor, I suffer from gas, 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 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 on a daily basis. Can I fast?
Heart burn which is a symptom of acid reflux in to food-pipe may worsen during fast and advice on such patients can be individualized. Many of such patients may fast with no problem if symptoms are controlled with acid reducing pill taken once a day.

Doctor, I have suffered from black motion due to ulcer in the stomach. Can I fast?
Patients with active ulcer disease cannot fast till ulcer heals and any precipitating cause of ulcer like Helicobacter pylori infection is eradicated or ulcerogenic drugs withdrawn. Patients with silent ulcers or those who have had bleeds from ulcers should not fast as fast may precipitate bleed or cause ulcer perforation. Some physicians believe that patients with peptic ulcer disease can fast as fast may improve their symptoms and promote ulcer healing. This concept is wrong. There is definite increase in 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 definite increase in acid and hormone Gastrin (which produces acid from stomach) during fast which persists for a month or more after 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 fatty liver and want to fast. Can I fast with safety?
Patients with non-alcoholic fatty liver (NAFLD) can safely fast and even Ramadan fast may be useful to control weight and dyslipidemia.  Patients with chronic liver diseases which are stable impose no added risk with fasting. However, chronic liver disease which shows signs of liver failure may worsen with fast and such patients need advice accordingly.

Doctor, Fidya applies to whom?
Fidya is a donation type within the Islamic Shariah paid by individuals who cannot fulfill the obligation of Ramadan fast due to illness or old age. Fidya payments are meant to feed a  needy for each of the fasting days missed and are equivalent to the price of one meal each for 2 people or 2 meals for one person. The price is based on the average cost of a basic meal in the country of residence. As per Ramadan Fidya project 2012 (Hyderabad, India) the cost of food grains required for one person to observe fasts for 30 days is rupees 1500/- (rupees 50/- per day) in India. The estimated cost, on guidance from the Fiqh Council of North America is $ 10 for each day missed or $ 300 for all the days of Ramadan in North America. Of course, if on average, you spend more per meal it is permissible to adjust the price accordingly. In addition, if the donor is from a low income family he or she should then care for the family’s needs before considering giving a separate Fidya donation.

Author is former Director, Dean, Professor & Head Gastroenterology & Chairman Dept. Medicine, Sher-i-Kashmir Institute of Medical Sciences, Srinagar, Kashmir, J&K, India. He is also former Consultant & Head Gastroenterology, Hepatology & Liver Transplantation, King Faisal Specialist Hospital & Research Centre. Riyadh, Saudi Arabia
khuroo@yahoo.com

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