Advice on health during Ramadan,
by Professor Saghir Akhtar
Ramadan is a month where believers learn to exercise self-control. A major facet of this is the abstinence from food and drink that is prescribed to all healthy Muslims during the hours of sunrise to sunset. Although the sick are exempt, many continue to fast and therefore abstain not only from eating and drinking water but also from consuming oral medications and intravenous nutritional fluids. This article provides a personal reflection on what advice might be pertinent for fasting Muslims in good health and those on medication.
Advice on diet
There is no receptacle more odious to God, than a belly stuffed full of food after a fast
During this year where Ramadan falls in the winter, and the long hot days of the summer a mere distant memory, most of the health problems are likely to arise from inappropriate diet, over-eating and insufficient sleep. Firstly, there is no need to consume excess food at Iftar (the food eaten immediately after sunset to break the fast), dinner or Sahur (the light meal generally eaten about half an hour to one hour before dawn). The reasons for this are two-fold. Firstly and most importantly such a lifestyle contradicts the principal aims and spirit of Ramadan. A learned scholar once said that "There is no receptacle more odious to God, than a belly stuffed full of food after a fast" and therefore "of what use is the Fast as a means of conquering God's enemy and abating appetite, if at the time of breaking it one not only makes up for all one has missed during the daytime, but perhaps also indulges in a variety of extra foods?" Indeed, there is a concern that it is becoming customary for some to "stock up" for Ramadan, so that more is consumed during this time than in the course of several other months combined. It is therefore worth reflecting on the true objective of fasting which is to experience hunger and to check desire in an attempt to reinforce the soul in piety.
Secondly, the body has regulatory mechanisms that reduce the metabolic rate and ensure efficient utilization of the body's fat reserves in times of hunger. Add to this the fact that most people assume a more sedentary lifestyle whilst fasting and the implication is that a balanced diet that is even less in quantity that normal will be sufficient to keep a person healthy and active during the month of Ramadan.
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. (Vegetarians and Vegans should amend this list as appropriate). Intake of fruits after a meal is strongly suggested. In actual fact, our diet in Ramadan should not differ very much from our normal diet and should be as simple as possible. The diet should be such that we maintain our normal weight, neither losing nor gaining. However, if one is over-weight, Ramadan is an ideal time to shed those extra pounds!
In view of the long hours of fasting, we should consume the so-called 'complex carbohydrates' or slow digesting foods at Sahur so that the food lasts longer (about 8 hours) making you less hungry during the day. These complex carbohydrates are found in foods that contain grains and seeds like barley, wheat, oats, millet, semolina, beans, lentils, wholemeal flour, and unpolished rice.
In contrast, refined carbohydrates or fast-digesting foods last for only 3 to 4 hours and may be better taken at Iftar to rapidly restore blood glucose levels. Fast-burning foods include foods that contain sugar and white flour. Dates are an excellent source of sugar, fibre, carbohydrates, potassium and magnesium and have been recommended since the days of the Prophet Mohammed (pbuh) as a good way of breaking the fast.
Fried foods, very spicy foods and foods containing too much sugar such as sweets, the delight of many Muslims, can cause health problems and should be limited during Ramadan. They cause indigestion, heart-burn, and weight problems. Fasting can often increase gastric acidity levels in the stomach causing a burning feeling, a heaviness in the stomach and a sour mouth. This can be overcome by eating foods rich in fibre such as whole wheat bread, vegetables, humus, beans and fruits. These foods trigger muscular action, churning and mixing of food, breaking it into small particles, and thus help reduce the build up of acid in the stomach.
Drinking of sufficient water and juices between Iftar and sleep to avoid dehydration and for detoxification of the digestive system should be encouraged in fasting individuals. However, the intake of large amounts of caffeine-containing beverages should be avoided especially at Sahur. For example, drinking too much tea will make one pass more urine and inevitably cause the loss of valuable mineral salts that your body would otherwise need during the day. Fruits such as bananas are a good source of potassium, magnesium and carbohydrates. However, bananas can cause constipation and their intake has to be balanced with adequate fibre intake.
It is recommended that everyone engage in some kind of light exercise, such as stretching or walking. Exercise, together with a balanced diet, should help everyone watch their weight during Ramadan. Anyone overweight should increase the amount of exercise and reduce the amount of food intake to help reduce weight.
It is also important to follow good time management procedures for Ibada (prayer and other religious activities), sleep, studies, work, and physical activities or exercise. A good balance in the amount of time attributed for each activity will lead to a healthier body and mind in Ramadan.
Advice for the sick who fast during Ramadan
Ramadan fasting is obligatory for the healthy adult but when fasting may significantly affect the health of the fasting individual or when one is genuinely sick, Islam exempts him from fasting. "God intends every facility for you, he does not want to put you into difficulties" (Quran 2:185). However, a significant number of ill patients, for whatever reasons, do decide to observe the fast. And it is these patients who need to seek the opinion of health professionals on an individual basis.
Those suffering from minor ailments really do not have any problems fasting. Those suffering from acute conditions may need advice about altering their dosing regimen i.e. the amount and frequency of their medication. Drugs that are normally required to be taken frequently, such as many antibiotics, can be problematic for the fasting patient. However, the increasing availability of alternative drugs with long half-lives (circulation times in the body) and the increasing formulation of short-acting drugs as sustained release preparations have offered much needed assistance to fasting patients.
For example patients suffering from acute upper respiratory infections such as a severe sore throat may still be able to fast. Normally such a patient may be prescribed antibiotics that have to be taken 3 or 4 times a day and would not be able to fast. However in order to facilitate fasting, the patient could be given a long-acting antibiotic such as Septrin (co-trimaxozole), which only needs to be taken once every 12 hours, or Zithromax (azithromycin), which only needs to be taken once daily. This can only be done when the infecting organisms are treatable with the alternative antibiotics and this needs to be discussed with the patient's own medical practitioner on a case-by-case basis.
An example where alternative routes of drug administration may help fasting patients is the use of transdermal (skin) patches. For example some patients suffering from mild forms of angina pectoris, a heart condition, could benefit from taking their medication, glyceryl trinitrate, as a skin patch rather than sub-lingual tablets. Here, the drug would be effective by entering the blood stream through the skin, and not orally (which would break the fast). Again, this may only be possible in specific patients and needs to be discussed with the patient's doctor. Pharmacists are generally willing to advise patients on the availability of alternative dosage forms for medication during Ramadan.
An example of where sustained release formulations may help is that of the fasting patients suffering from mild forms of hypertension (high blood pressure). These patients can be given their drug in formulations that only require once-daily dosing. Here the drug can be administered orally at Sahur and the special formulation then allows the drug to slowly release into the body over a day. In fact, there is a school of thought among medical practitioners that those patients who have mild to moderate high blood pressure and are also overweight should be encouraged to fast as fasting may help to lower their blood pressure. Such patients should see their physician to adjust medication. For example, the dose of diuretics should be reduced to avoid dehydration, and sustained release formulations such as Inderal LA can be given once a day before the pre-dawn meal.
An increasing case where practitioners are likely to advise patients on fasting is in those suffering from Diabetes mellitus . Many Muslims, especially of Asian descent, have an increased risk of suffering from some form of diabetes. The International Journal of Ramadan Fasting Research has suggested the following guidelines for health professionals treating Muslim patients with diabetes: "Diabetic patients who are controlled by diet alone can fast and hopefully, with weight reduction, their diabetes may even be improved. Diabetics who are taking oral hypoglycaemic agents along with the dietary control should exercise extreme caution if they decide to fast. These patients should consult their medical doctor for dose adjustment. If they develop low blood sugar symptoms in the daytime, they should end the fast immediately."
In addition, diabetics taking insulin should consult their doctor to see if their dose can be adjusted for them to fast during Ramadan. In all cases of Muslim diabetics fasting, they should closely monitor their blood sugar levels especially before and after meals.
In summary, Islam offers an exemption to the sick from observing their fast during the holy month of Ramadan. However, some patients may be able to fast if their health is not adversely affected during the period of fasting. In such cases, advice from pharmacists and doctors about changing prescriptions to equally effective drugs that have reduced dosing, such as sustained release formulations, may be beneficial to the fasting Muslim. In all cases of illness, it is recommended that Muslim patients, if they do fast, do so under medical supervision.