Written by Zainab Haque, MS, RDN, LDN
Each year, Muslims worldwide look forward to Ramadan, their most sacred time of year. Muslims consider Ramadan a holy month in which they fast from sunrise to sunset to strengthen their spiritual relationship and revitalize their faith. Fasting is one of the five pillars of Islam and is obligatory for healthy adult Muslims. It falls on the ninth month in the Islamic calendar; however, since it is based on the lunar calendar, the timing of Ramadan fluctuates year to year. Depending on geographical location, the fasting period can last between 11-20 hours. No food, water, or medications are consumed during the fast – therefore, many Muslims with pre-existing conditions are exempt from fasting including:
- the elderly
- those with illnesses
- anyone with an intellectual or developmental disability
- pregnant or breastfeeding women
- menstruating women
- young children
- travelers
For those that are fasting, there is a meal eaten before sunrise, referred to as suhoor. A meal is eaten to break the fast at sunset, referred to as iftar. The month comes to an end with a three-day celebration, Eid-al-Fitr, filled with festivities, joy, and time spent with loved ones.
Physiology of Fasting in Ramadan
The fed-fast cycle consists of 4 stages: fed state -> early fasting state -> fasting state -> starvation state. The first two stages pertain to fasting during this time.
Fed State: This stage occurs 0-4 hours after consuming a meal while the body is digesting and absorbing nutrients. Insulin is secreted in greater amounts and shifts glucose into the cells.(1) Hormonal shifts are occurring at the same time. Ghrelin, responsible for stimulating hunger, decreases while leptin, responsible for satiety, increases.
Early Fasting State: This next stage lasts between 4-18 hours. Glucose and insulin levels decrease, driving the body to begin utilizing glycogen for energy instead. When the body runs out of glycogen stores, gluconeogenesis kicks in and turns to fat and some protein as its next fuel source.(1)
Effect Of Fasting On Major Disease States
Fasting in Ramadan closely resembles the popular form of intermittent fasting (IF) referred to as the 16:8 method, where fasting occurs for 16 hours, and the remaining 8 hours are reserved for eating. Much of the research that examines the effects of fasting on a patient’s health focuses on intermittent fasting.
Diabetes: Patients with diabetes are at risk for complications such as hypoglycemia and hyperglycemia, going through extended periods of fasting and periods of a high volume of eating. On the other hand, there may be some potential benefits, such as improved insulin sensitivity. A systematic review aimed to examine the effect of intermittent fasting on type 2 diabetes. Results showed that IF was an effective approach to weight loss, decreasing insulin resistance and fasting glucose.2 During Ramadan, provider may want to consider holding meal-time insulin, reducing basal insulin doses, as well as adjusting timing of oral medications to when patients will be eating to prevent hypoglycemia.
CVD: Pro-inflammatory markers are associated with atherosclerosis. A study investigating the effect of IF in Ramadan on inflammatory markers showed a decrease in interleukin-6, c-reactive protein, and homocysteine.(3) It demonstrated that fasting might have some positive benefits on the body's inflammatory status. An observational study conducted analyzing the association between fasting and hypertension showed a decrease in systolic and diastolic blood pressure, triglycerides, and cholesterol while fasting.(4)
Renal: A systematic review examined the effect of fasting on renal patients. The results are not generalizable as most of these studies were observational. However, the review concluded that stable patients with CKD not on dialysis may be able to fast with close supervision. Still, patients on hemodialysis or peritoneal dialysis were considered very high risk due to possible electrolyte imbalances and therefore fasting is not recommended in these patients.(5)
Much of the existing research on fasting during Ramadan is observational and not always generalizable. Human studies on intermittent fasting have been growing steadily, and further research regarding the effect of fasting on specific disease states is needed to make more concrete recommendations.
How Can Providers Assist Patients During This Time?
Healthcare providers should be informed of the implications of Ramadan so they can provide the best possible care for Muslim patients and minimize the risk of complications. Although specific populations are exempt from fasting, some individuals choose to participate anyway as they feel a deep spiritual connection during this month.
Patient education is a crucial aspect of providing care. Having a conversation between the patient and provider to determine the best way to navigate this period will help tremendously. Scheduling appointments before and after Ramadan can be an effective way to assess risks, inform patients of medical recommendations, and follow up to ensure it is a safe and tolerable practice.
Every patient is unique and fasting can pose risks depending on multiple factors. Timing of medications, the type of medication taken, and physiological consequences are just a few factors to consider. Patients should always speak to their healthcare provider and consider medical advice before deciding to fast.
For what is currently known and more in-depth information regarding diabetes, CKD, CVD, and fasting in Ramadan, please visit International Diabetes Federation’s Guidelines.
References:
- Stockman M-C, Thomas D, Burke J, Apovian CM. Intermittent Fasting: Is the Wait Worth the Weight? Current Obesity Reports. 2018;7(2):172-185. doi:10.1007/s13679-018-0308-9
- Albosta M, Bakke J. Intermittent fasting: is there a role in the treatment of diabetes? A review of the literature and guide for primary care physicians. Clinical Diabetes and Endocrinology. 2021;7(3). doi:10.1186/s40842-020-00116-1
- Aksungar FB, Topkaya AE, Akyildiz M. Interleukin-6, C-reactive protein and biochemical parameters during prolonged intermittent fasting. Annals of Nutrition & Metabolism. 2007;51(1):88-95. doi:10.1159/000100954
- Malinowski B, Zalewska K, Węsierska A, et al. Intermittent Fasting in Cardiovascular Disorders-An Overview. Nutrients. 2019;11(3):673. doi:10.3390/nu11030673
- Malik S, Bhanji A, Abuleiss H, et al. Effects of fasting on patients with chronic kidney disease during Ramadan and practical guidance for healthcare professionals. Clinical Kidney Journal. 2021;14(6):1524-1534. doi:10.1093/ckj/sfab032
