Shahid Athar, MD, FACP, FACEAuthor, “Islamic Perspective in Medicine” (ATP)

Ramadan Fasting and Ramadan Fasting and Muslim PatientsMuslim Patients

AbstractAbstract

“ Fasting from dawn to dusk in the holy month of Ramadan for healthy adult Muslims has been ordained and physically sick Muslims are exempt from it. However many Muslims with mild to moderate Diabetes, Hypertension and other medical conditions do want to fast. The purpose of this presentation is make some recommendations as to how they can fast safely in light of research on fasting”

Quran 2:183Quran 2:183

“ O you who believe! Fasting has been prescribed to you as it was prescribed to those before you so that you attain Taqwa (self restraint , God Awareness)”

Who Cannot FastWho Cannot Fast

1. Physically sick ( Quran 2: 184-185)

2. Traveler on a journey (above)

3. Women during menstruation

4. ? Pregnant and lactating women

5. pre pubertal children

Physiological Effects of FastingPhysiological Effects of Fasting

• On Calorie intake

• On fluid /water intake

• Effects on – Digestive System

- Kidneys

- Endocrine glands

- Lipid Metabolism

- Respiratory system

- Neurological System

Uniqueness of Islamic FastingUniqueness of Islamic Fasting

• It is a voluntary undertaking rather than being ordered by a physician

• There is no selective food intake i.e. protein only, juice only, fruit only , water only etc

• There is no total calorie malnutrition i.e. it not a semi starvation diet.

• An exercise in self discipline i.e. from constant nibbling , drinking, smoking etc

• Psychological effect and additional prayer

Effects of Fasting on Effects of Fasting on Carbohydrate MetabolismCarbohydrate Metabolism

1. Slight fall in serum Glucose (to 60 mg)

2. Serum Insulin decreases due to 1

3. Serum Glucagon and Growth Hormone increases due to 1

4. Increase in sympathetic activity

5. Increase in liver Cyclic AMP due to 4

CHO Metabolism in RamadanCHO Metabolism in Ramadan

• Slight decrease in first week then normalization by day 20 and some rise in the last week

• 22% children develop hypoglycemia (BG <40mg/dl)

• Increase Gluconeogenesis in liver

Fasting and Lipid MetabolismFasting and Lipid Metabolism

• Decrease in both Total Cholesterol and Triglycerides in first few days then rise to pre fasting levels

• Increase in HDL-C

• Effects are variable according to quality and quantity of food consumed at Iftaar and Sahur

Endocrine functions in FastingEndocrine functions in Fasting

• Fall in free T3 but rise in rT3

• Slight fall in total T4 (due to fall in TBG) but normal freeT4 and TSH

• TSH response to TRH unchanged

• Serum Testosterone, LH, FSH may be normal or slightly low but GNRH response is normal

• Plasma Prolactin and PTH are normal

Renal Function in FastingRenal Function in Fasting

• Urinary volume, osmolality, solute and electrolyte excretion remain normal

• Slight increase in BUN (insignificant)

• Increase in Uric acid (less in Ramadan fasting than in prolonged fasting)

Other Effects of FastingOther Effects of Fasting

• Slight rise in Bilirubin but no change in SGOT or SGPT

• Fall in Gastric secretions

• No change in Heart rate and BP

• No change in Ca+ or Electrolytes

• No change in Hb, blood counts or Fe store

Other Effects of FastingOther Effects of Fasting

• Weight loss of 1.7-3.8 Kg (obese lost more weight than non obese)

• Decrease in appetite due to ketosis and increase in Beta-endorphins

• Fewer suicide in Ramadan than in other months (reported in Jordan)

• No change in outcome of pregnancy or in birth weight in those who fasted and those who did not (reported in Gambia)

Patients who should not fastPatients who should not fast

• Diabetes Mellitus Type 1

• Chronic Renal Failure including Renal Transplant and Nephrolithiasis

• Severe cardiac and pulmonary conditions

• G.I. Bleed and acute ulcers

• Severe Epilepsy

• Severe Migraine

General advice for those who fastGeneral advice for those who fast

• Consult your (Muslim) doctor first• Practice fasting in Shaban first• With the approval of physician switch to

either long acting or twice daily medication

• Elderly patients on NSAID should have frequent monitoring of renal functions

• Anticoagulant and Antiepileptic medications should be given at night .

Fasting for NIDDM (ref:3)Fasting for NIDDM (ref:3)

Benefits of Fasting in Ramadan

• A. Better control of Diabetes

• B. Better control of Hypertension

• C. Better control of Lipid

• D. 5-10 lb weight loss

Thus Fasting is advised for stable NIDDM

NIDDM- RecommendationsNIDDM- Recommendations

• Control your Diabetes for two months prior to Ramadan bringing HbA1c to < 8

• Discontinue Metformin a week before fast• Drugs like Actos, Avandia , Glucotol XL are

safer than Diabeta, Amyril , and Starlix• Continue Diabetic diet in Iftaar and Sahur

Fasting for those on InsulinFasting for those on Insulin

• Consult your Diabetologist (Muslim) first

• Discontinue Insulin mixtures such as 70/30 , 75/25, or Regular Insulin

• If on NPH then reduce the total dose by 20% and take 2/3 at Iftaar and 1/3 at Sahur

• If on Lantus then reduce by 20% and take at night -Titrate by 2 units ( BG 120-140)

• Take 4-6 units of fast acting Insulin such as Novolog or Humalog before two meals

Monitoring for IDDMMonitoring for IDDM

• Finger stick BG after Iftaar and before sahur

• BG if feeling bad (low)• Terminate fast if BS below 60 or over

400• No exercise before Iftaar• Drink plenty of water at iftaar and

Sahur

Questions from MuslimsQuestions from Muslims

• Fasting and Pregnancy

• Fasting and Nursing

• Blood draw during Fasting

• Medications during Fasting

-Tablets, inhalers, patches , injections

• Exercise / Sports during Fasting

• Mouth washes and gums during Fasting

ReferencesReferences

• Azizi , F et all” Evaluation of blood hormones and constituents in Ramadan” JIMA, Nov. 1987

• Soliman , N “ Effects of Fasting during Ramadan” JIMA Nov 1987

• Athar, Shahid “Management of NIDDM during Islamic Fasting in Ramadan :JIMA vol 27 1995

• Athar , Shahid “Fasting for Medical Patients-suggested guidelines” Islamic Horizon, May ’85

• Athar , Shahid “Therapeutic Benefits of Ramadan Fasting” Islamic Horizon: May’ 84

Some Parting ThoughtsSome Parting Thoughts

• “Fasting is for Me and I (Allah) only will reward it” (Hadith Qudsi)

• “While fasting , if one does not give up falsehood in words and actions , then Allah has no need of him giving up food and drink (saying of Prophet Muhammad-pbuh)

HAVE A BLESSED RAMADAN

THANK YOUTHANK YOU

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