Fasting during Ramadan: a Muslim pharmacist’s perspective
The Muslim holy month of Ramadan, in which Muslims fast from just before sunrise to sunset each day, is upon us again. This year it begins in mid-November. Special issues that may arise in a pharmacy during Ramadan include providing advice on appropriate diet and on medical compliance among the Muslim population. In this article, I provide a personal perspective of why Muslims fast and, as a Muslim pharmacist, what advice I consider may be appropriate for fasting customers both healthy and those on medication, such as diabetic patients
The observance of fasting during Ramadan constitutes one of the five pillars of Islam. The experience of fasting is intended to teach Muslims self-discipline and self-restraint, and understand a little of the plight of the less privileged (e.g., the hungry, thirsty and the poor). Furthermore, Ramadan fasting is not just about disciplining the body to refrain from eating and drinking from predawn until sunset but is also about exerting control over the mind. This involves restraining anger, doing good deeds, exercising personal discipline, and preparing oneself to serve as a good Muslim and a good person. Ramadan is a month of peace and love in which individuals are encouraged to bury differences, to forget and forgive and to renew both human and spiritual relationships. Therefore, it contributes to the overall principle of making the individual more humane, more considerate and generally a more responsible member of society. In this way, the month of Ramadan ultimately benefits society not just the individual. It does this, in part, by setting a standard for behaviour not only in this month but during the rest of the year and, indeed, every year of a Muslim’s life. These principal tenets of Ramadan are important when considering our intentions and subsequent actions during this spiritual month, including those pertaining to the health of the individual.
Fasting during Ramadan is prescribed for every healthy, adult Muslim whereas the weak, the sick, children, travellers and menstruating women are among those exempt. Muslims observing the fast are required to abstain not only from eating food and drinking water but also from consuming oral medicines and injecting intravenous nutritional fluids. However, not all Muslims who are ill seek this exemption and insist on fasting in any case. Fasting by Muslims during illness can cause problems if not supervised by health professionals. However, health problems during Ramadan can develop in otherwise healthy individuals and such patients could benefit from receiving advice on their diet.
When does Ramadan begin?
Ramadan is the month in which the first verses of the Koran were revealed by God to the Prophet Mohammed. It traditionally begins when the new crescent moon (hilal) of Ramadan, the ninth lunar month of the Islamic calendar, is sighted. The period of fasting starts the morning after the birth of the new moon and ends with the sighting of the birth of the next new moon.
If the new moon is not visible due to cloud or fog, then the beginning and end of Ramadan are determined by counting the days of the month. Fasting begins the morning after the 30th day of the previous month. Similarly, the fast is broken the morning after the 30th day of Ramadan is complete.
This year, Muslims throughout the world will begin to search the sky for the new crescent moon from 15 November.
Advice on diet
During this year where Ramadan falls in the winter, and we do not have the very long days of the summer heat to contend with, most health problems are likely to arise from inappropriate diet or as a consequence of over-eating and insufficient sleep.
There is no need to consume excess food at iftar (the food eaten in the period immediately after sunset to break 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. First, and most importantly, such a lifestyle contradicts the principal aims and spirit of Ramadan. Over-eating can be seen as a reflection of weak discipline and irresponsibility. Secondly, the body has regulatory mechanisms that reduce the metabolic rate and ensure efficient utilisation of body fat. Furthermore, most people assume a more sedentary lifestyle while fasting. The net result is that a balanced diet, that consists of less than the normal amount of food intake, is sufficient to keep a person healthy and active during the month of Ramadan.
To remain healthy during Ramadan, one should consume food from the major food groups: bread and cereal, milk and dairy products, fish, meat and poultry, beans, vegetables and fruits. (Vegetarians and vegans should amend this list as appropriate.) Intake of fruits after a meal is strongly suggested. Diet in Ramadan should not differ much from the normal diet and should be as simple as possible. The diet should be such that normal weight is maintained, neither losing nor gaining. However, if one is overweight, Ramadan is an ideal time to try to normalise one’s weight.
In view of the long hours of fasting, the so-called “complex carbohydrates” or slow digesting foods should be consumed at sahur so that the food lasts longer (about eight hours) resulting in less hunger 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 three to four hours and may be better taken at iftar to restore blood glucose levels rapidly. Fast-burning foods include those 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 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, heart-burn and weight problems. Fasting can often increase gastric acidity levels 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, hummus, beans, and fruits. These foods trigger muscular action, churning and mixing 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 increase urine output and inevitably cause the loss of valuable mineral salts.
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. Overweight people 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 might significantly affect the health of the fasting individual or when one is genuinely sick, Islam exempts him or her from fasting. “God intends every facility for you, he does not want to put you into difficulties” (Koran 2:185). From an Islamic point of view, this exemption represents more than a simple permission not to fast. The Prophet said: “God likes his permission to be fulfilled, as he likes his will to be executed.” Another saying suggests that “a gift that God gives you, you have to accept”. In the light of these sayings, many believe that any Muslim who is sick, or whose sickness would adversely affect his well-being during the fasting period, should either not fast or at least break his fast accordingly. An additional argument often used is that if the fasting by a sick Muslim would jeopardise his health further, then this ultimately will neither benefit himself nor his role in society (Ummah) and he should be discouraged from observing the fast.
However, a significant number of patients, for whatever reasons, do decide to observe the fast. It is these patients who need to seek the opinion of health professionals on an individual basis.
Those suffering from minor ailments do not really have any problems fasting. Those suffering from acute conditions may need advice about altering their dosing regimen. Drugs that are normally required to be taken frequently, such as antibiotics, can be problematic for fasting patients. However, the increasing availability of alternative drugs with long half-lives as well as 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. Such a patient might be prescribed antibiotics that have to be taken three or four 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 co-trimoxazole, which only needs to be taken 12- hourly, or azithromycin, which only needs to be taken once daily. This can be done only when the infecting organisms are susceptible to the alternative antibiotics, and needs to be discussed with the patient’s doctor.
Alternative routes of drug administration can help fasting patients. Some patients suffering from mild forms of angina pectoris could benefit from taking glyceryl trinitrate as a patch rather than sublingual tablets. The drug would enter 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 should be willing to advise patients and practitioners on the availability of alternative dosage forms for medication during Ramadan.
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 this may help to lower their blood pressure. Such patients should see their physician to adjust their medication. For example, the dose of diuretics should be reduced to avoid dehydration, and sustained release formulations can be given once a day before the predawn meal.
An increasing area 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, diabetic patients taking insulin should consult their doctor to see if their dose can be adjusted to allow fasting during Ramadan. In all cases of fasting with diabetes, blood sugar levels should be closely monitored, 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. Pharmacists, doctors and other health professionals are undoubtedly keen to help.
Professor Akhtar is chairman of the Department of Pharmaceutics