Fasting during the month of Ramadan is one of the five pillars of Islam and one of the essential commitments to faith for every Muslim. Amongst many other things, fasting must serve the purpose of self-control and self-discipline.
Health and 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 actual practice, our diet during 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 overweight, Ramadan is an ideal time to shed those extra pounds!
Sahoor meal
Given 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 us less hungry during the day. These complex carbohydrates have a low glycaemic index and take a long time to convert to glucose in the body and help maintain blood glucose in the late afternoon. Such foods include grains and seeds like barley, wheat, oats, millet, semolina, beans, lentils, whole meal flour, and unpolished rice.
Iftaar meal
For the Iftaar meal, we must alter the contents of our meal. 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. Fast-burning foods include foods that contain sugar and white flour. Dates are an excellent source of sugar, fiber, carbohydrates, potassium, and magnesium and have been recommended since the days of the Prophet Muhammad (PBUH) as a good way of breaking the fast.
Food
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. Fasting can often increase gastric acidity levels in the stomach causing a burning feeling, heaviness in the stomach, and a sour mouth. This can be overcome by eating foods rich in fiber such as whole wheat bread, vegetables, hummus, beans, and fruits. High-fiber diets have an excellent effect on our satiety and are most suited for Ramadan. In addition, these foods trigger muscular action, churning and mixing of food, breaking it into small particles, and thus helping reduce the build-up of acid in the stomach.
Dehydration and hypoglycemia
Ramadan’s fast duration (dawn-to-dusk period) varies from one geographical region to another and from year to year. In 2023, we would strike the fast duration extending around 14 hours. Some regions of the World may have fasting periods even longer extending from 16 to 18 hours. These long periods of fasting especially during summer heat can cause considerable water loss through sweating and other insensible sources and may affect glucose metabolism, leading to dehydration and hypoglycemia. Several groups of people are prone to such a phenomenon. These include children, elderly people, pregnant women, frail, weak, and underweight, persons, with underlying medical conditions, etc. Many precautions are needed to avoid dehydration and hypoglycemia. One should drink enough water, especially at Sahoor, and limit intake of caffeine-containing beverages namely tea and coffee. Caffeine is a diuretic and will not provide adequate hydration. Sudden withdrawal of tea and coffee from the diet can cause headaches, mood swings, and irritability. Thus, the intake of such beverages should be slowly curtailed over a few days to a week. Direct exposure to the sun, physical labor, or exercise in the open and during late afternoon should be avoided. Also, fast can be broken if such persons feel weak, faint on getting up, or get exhausted.
Smoking, exercise and fast
Ramadan is an excellent opportunity to stop smoking. Smoking negatively affects the utilization of various vitamins, metabolites, and enzyme systems in the body. It is recommended that everyone engage in some kind of light exercises, such as stretching or walking. However, it is not advisable to undergo hard strenuous exercises like Gym workouts, etc., especially in the late afternoon. It’s important to follow good time management practices for prayer and other religious activities, sleep, studies, job, and physical activities or exercise. The effect of the Ramadan fast on International Muslim players in important national & international games has been a matter of concern. However, a study on Muslim football players concluded that biochemical, nutritional, subjective well-being, and performance variables were not adversely affected in young male international-level players who followed Ramadan fast in a controlled environment.
Medication recommended during fasting
It is not easy to give a unified view on practices that nullify fast and should be left to the judgment of the physician and the personal preferences of the individual depending upon his beliefs. There is broad consensus that the following routes of drug administration do not break the Ramadan fast: Eye and ear drops; all substances absorbed into the body through the skin, such as creams, ointments, and medicated plasters; nitroglycerine tablets placed under the tongue for the treatment of angina; mouthwash, gargle, or oral spray, provided nothing is swallowed into the stomach; nose drops, nose sprays, and inhalers. The use of inhalers for the treatment and control of asthma during Ramadan needs to be critically evaluated as per individual beliefs.
Dosage schedule
Drug dosing schedules and drug-food interactions are complex and outside the domain of most practicing physicians. It is advisable that physicians take the help of pharmacy services and access knowledge through the literature on both these phenomena.
During Ramadan fast, drug doses can be taken only between Dusk (Iftaar) to Dawn (Sahoor), not from Dawn to Dusk. The period for drug intake is thus shorter than outside Ramadan fast. Two different types of dosage schedules are commonly used during Ramadan. For patients on a single daily dose, the easiest situation is that of patients who have a usual evening dose. Their therapeutic scheme remains unchanged during Ramadan, as it does not interfere with fasting. When the usual intake is in the morning or during the day, the doctor must be careful when delaying the intake to the evening so that this will not alter the efficacy of treatment or the tolerance of the drug. The efficacy and toxicity of many drugs can vary depending on the time of administration about the circadian rhythms of biochemical, physiological, and behavioral processes. Thus, the circadian time must be taken into account as an important factor influencing a drug’s pharmacokinetics or its effects or side effects. For patients on two or more daily doses during Ramadan, accurate distribution of drugs prescribed twice a day is difficult to achieve between the break from fasting (Iftaar) and the beginning of fasting (Sahoor). Refraining from fasting according to the Islamic rules could be a wiser prescription, but not possible. Nonetheless, patients with two doses could take the first one at the break of fasting (Iftaar) and the second one before the beginning of fasting (Sahoor), in which case the dosing time and the period between the doses are both altered. These alterations could affect the drug’s plasma concentration profile and, therefore, its efficacy and tolerance. This is even more relevant for drugs with a narrow therapeutic index as the risk of toxicity is higher.
Drug-food interaction
Generally, drug-food interactions may result in reduced, delayed, or increased systemic availability of a drug. The degree of interaction, and whether it positively or negatively affects drug absorption, depends on several factors, including the physical and chemical nature of the drug, the formulation, the type of meal, and the time interval between eating and dosing.
The last two factors could have an enhanced effect during the month of Ramadan, as the rhythm and composition of meals are modified. The quality of the food eaten during the fast-breaking meal could also have an influence on the absorption of some drugs.
Beverages such as tea, coffee, and orange juice can increase gastric acidity, which increases the absorption of weak acids such as salicylates, dipyridamole, Sulfamide, and some antibiotics and hypnotics; the action of pethidine, amitriptyline, and antihistamines may be inhibited.
The high concentration of fat and carbohydrates at this meal could alter the bioavailability of drugs, but this alteration depends on the formulation used.
For example, the intake of free acid phenytoin, as Hydantoin powder, with a high-fat meal increased its bioavailability, whereas the intake of an extended-release phenytoin sodium formulation with a high-fat meal decreased its bioavailability.
The clinical impact of such interactions depends on the narrowness of the drug’s therapeutic index. An alteration in bioavailability because of these interactions could have a substantial effect on the plasma concentration of a drug, particularly a drug with a narrow therapeutic index, leading to reduced efficacy or increased side effects.
For further information on this subject, I would recommend all to watch “Your Ramadan Fast in Health & Disease. https://youtu.be/Hg0a4aEOb5Y’. and access and read my book “Ramadan 2014. Your Medical Guide”.
(Prof Mohammad Sultan Khuroo is a renowned gastroenterologist. He can be mailed at khuroo@yahoo.com. mohammad.khuroo@gmail.com)
DISCLAIMER: The views and opinions expressed in this article are the personal opinions of the author.
The facts, analysis, assumptions and perspective appearing in the article do not reflect the views of GK.