Research Commentary  June 2018
Jun 2, 2018
This review focuses on caring for Muslim patients during Ramadan.
During the Holy Month of Ramadan, healthcare professionals need to apply a culturally sensitive and respectful approach to the care and treatment of their Muslim patients. Clinicians who understand the Muslim world view and religious or cultural practices are better placed to provide culturally appropriate, person-focused care to Muslim patients.
Islam is made up of the Five Pillars, or basic rituals. These are the profession of faith, daily prayer, annual alms, pilgrimage to Mecca, and fasting during the holy month of Ramadan. Ramadan is celebrated for 29 or 30 days in the ninth month of the Islamic calendar, depending on the lunar cycle. Ramadan requires fasting from dawn to dusk, during which time Muslims refrain from eating, drinking, having sex, and smoking.
There is a great diversity of cultural, ethnic and linguistic groups within Muslim communities, each of whom have their own cultural characteristics and world views of health and illness. This diversity means that caring for Muslim patients presents constant challenges to healthcare providers.
During Ramadan, Muslim patients choose to fast because Ramadan is the most blessed and spiritually-beneficial month of the Islamic year. The benefits of fasting during Ramadan are that it encourages Muslims to empathise with the poor and the hungry, fosters one’s personal relationship with God, spiritual renewal and self-reflection.
According to the Koran, those who are sick or on a journey, or women who are menstruating, pregnant or nursing are permitted to break the fast and make up an equal number of days later in the year. Muslims who are sick, elderly or chronically ill for whom fasting is unreasonably strenuous are also exempt, but are required to provide food to at least one underprivileged person every day during Ramadan for which he or she has missed fasting. Other groups exempted from fasting include those with disabling mental illness or developmental disabilities, and older people.
Many Muslims who are exempt from fasting nonetheless choose to fast. Fasting Ramadan can have an effect on Muslim patients’ health and disease management. It is important for clinicians to be culturally competent and knowledgeable about the basics of Ramadan, exemptions from fasting, treatments and procedures that invalidate fasting, and the effects of fasting on managing patients with diabetes, cardiovascular, gastrointestinal, renal, and other common diseases. While clear guidelines are not always available for managing all diseases, an individualised approach is needed in treating fasting Muslim patients during Ramadan.
Commentary provided by Dr Annette Mortensen, eCALD® Services Project Manager: Research and Development
The following articles are reviewed:
Article 1: Early observations on the health of Syrian refugees in Canada
The Koran exempts the sick from fasting. This article focuses on risk stratification criteria to determine whether fasting is safe for patients with diabetes. Fasting is unsafe for patients with type 1 diabetes, but is generally considered safe for patients with well-controlled type 2 diabetes treated with oral agents.
Islamic law exempts women who are pregnant or breastfeeding from fasting. Nonetheless, many pregnant and breastfeeding women choose to fast during Ramadan.Women who do so should be advised to hydrate and consume nutritious foods during the predawn and evening meals. Clinicians should also give precautions against excessive daytime activity, and explain the warning signs that warrant breaking the fast, such as decreased foetal movement, extreme fatigue or dizziness, or nausea with vomiting.
The requirement to fast begins with puberty, so children are exempt from fasting. However, children often fast with their families for a portion of the day. Post pubertal adolescents generally fast. Those who are unaccustomed to fasting and participate in sports require special attention to avoid dehydration.
For those on medication, consuming oral medications during the fasting hours invalidates the fast, and patients often skip midday doses. Therefore, long-acting forms of medications or twice-daily dosing regimens are options during Ramadan. Intramuscular and subcutaneous injections, eye and ear drops, and routine blood draws do not invalidate the fast. Inhaled nebulizers and nasal sprays are generally allowed as long as the solution does not drain to the back of the throat. When in doubt about these or other issues, patients should be advised to consult their local religious leader.
Authors: Khalife, T., Pettit, J.M. & Weiss, B.D.
Citation: Khalife, T., Pettit, J.M. & Weiss, B.D. (2015). Caring for Muslim patients who fast during Ramadan. American Family Physician, 91 (9), 641-642.
Article 2: Muslim patients in Ramadan: A review for primary care physicians
While there are several exemptions from fasting during Ramadan (“Sawm”), many Muslim patients with acute or chronic medical conditions still choose to fast, which may adversely affect their health if not addressed properly. Health‑care providers need to learn how fasting Ramadan can affect the health of their Muslim patients, especially those with chronic medical conditions, and how to help them achieve safe fasting.
This article provides an overview of the main topics that primary care physicians may need to know about in order to improve their cultural competence when caring for their fasting Muslim patients. With careful support and advice, along with shared decision‑making regarding treatment plans, successful health outcomes and safe fasting can be achieved. The authors provide a useful summary of the type of medications and medical procedures and conditions that invalidate or do not invalidate fasting according to Islamic jurisprudence.
During Ramadan, two main meals are served: suhoor, which is served before dawn, and iftar, which is served after sunset. Ample fluids should be taken between iftar and suhoor to prevent dehydration. Maintaining a well‑balanced, healthy diet that is rich in fibre and low in salt is recommended.
Only moderate or low-risk patients whose diabetes is well controlled should fast. Diabetic patients should be counselled on the warning signs of hypoglycaemia and what to do if symptoms occur. Patients should be advised to eat a healthy balanced diet in two or three small meals, between iftar and suhoor, rather than one large meal to avoid postmeal hyperglycaemia.
A recent systematic review and meta‑analysis showed that Ramadan fasting is not associated with the risk of developing acute cardiovascular events (Turin et al., 2016). It is safe for patients with controlled high blood pressure to fast and it is recommended that they consult their GP a few weeks before Ramadan to adjust their medications, if needed. Those on a stable dose of statins may continue taking their medication during Ramadan, while newly prescribed statins may not be recommended as their side effects may negatively affect the fast.
Ramadan fast and gastrointestinal health
Symptoms of dyspepsia, including bloating, indigestion, and heartburn, are common in fasting patients, especially those who eat to excess during iftar or suhoor meals.Patients should be advised to eat moderately and avoid foods that can trigger these symptoms.
Patients with active peptic ulcers should be advised not to fast because of their higher probability of developing complications. On the other hand, patients with nonactive peptic ulcers can fast with using proton pump inhibitors, between iftar and suhoor, when needed. Patients with stable inflammatory bowel disease or chronic hepatitis may also be able to fast without negative consequences on their health.
Ramadan fast and patients with renal diseases
Fluid restriction and possible dehydration during fasting hours in Ramadan may raise a special concern about the health of patients with renal diseases.
Authors: Abolaban, H., & Al-Moujahed, A.
Citation: Abolaban, H., & Al-Moujahed, A. (2017). Muslim patients in Ramadan: A review for primary care physicians. Avicenna Journal of Medicine, 7(3), 81–87. http://doi.org/10.4103/ajm.AJM_76_17
Article 3: Recommendations for management of diabetes during Ramadan: update 2015
Although some Muslim patients are excused for health reasons, many may still wish to fast during Ramadan, including those with diabetes. The importance of monitoring blood sugars regularly should be reinforced, especially if fasting patients are insulin dependent. Pre-dawn and post-evening meals should be tailored appropriately and should, for example, include carbohydrates at the pre-dawn meal so as to release energy slowly throughout the day.
For diabetic patients, the importance of “breaking the fast” should be emphasised if blood glucose levels fall, placing the individual at risk of a hypoglycaemic condition. It is important for diabetes nurses to provide fasting-focused diabetes education to those with diabetes, given that structured education is well established in the management of diabetes.
Much of what is recommended for the management of patients with diabetes during fasting in Ramadan is based on expert opinion, and few randomised controlled studies have investigated best treatment regimens during Ramadan in patients with diabetes. Patients should be stratified into their risk of hypoglycaemia and/or the presence of complications prior to the beginning of fasting. Patients should be instructed that point-of-care testing does not break the fast and that glucose monitoring may reduce the risks of hypoglycaemia in patients receiving insulin secretagogues and insulin therapy.
The article has a useful management algorithm for people with type 2 diabetes intending to fast during Ramadan (HbA1c, glycated haemoglobin; SGLT-2, sodium glucose transporter-2 inhibitors; TZD, thiazolidinedione).
Interestingly, there is growing evidence of the beneficial effects of dates in improving glycaemic and lipid control in patients with diabetes and a possible reduction in cardiovascular risk factors.Daily consumption of dates is a deeply rooted tradition among Muslims, especially during Ramadan. Most Muslims consume dates when they break their fast (Iftar). Dehydrated dates are rich in carbohydrates, salts, minerals, vitamins, unsaturated fatty acids, proteins, and fibre. The GI of most common dates range between 35 and 55, with an average of 42.
Reference: Turin, T.C., Ahmed, S., Shommu, N.S., Afzal, A.R., Al Mamun, M., Qasqas, M., et al. (2016). Ramadan fasting is not usually associated with the risk of cardiovascular events: A systematic review and meta‑analysis. J Family Community Med, 23, 73‑81.
Authors: Ibrahim, M., Abu Al Magd, M., Annabi, F.A., et al.
Citation: Ibrahim, M., Abu Al Magd, M., Annabi, F.A., et al. (2015). Recommendations for management of diabetes during Ramadan: update 2015. BMJ Open Diabetes Research and Care, 3. e000108. doi:10.1136/bmjdrc-2015-000108
Article 4: Ethical conflicts in the treatment of fasting Muslim patients with diabetes during Ramadan
This article focuses on ethical conflicts and the important role of imams. The question of, if a Muslim in a given state of illness is allowed to fast has to be posed not only to doctors, but also to imams or muftis (Muslim theologians). This review suggests that the importance of imam consultations for adherence to treatment is higher than previously assumed. Additionally, imams advise practising Muslims about the compatibility of certain interventions with the fast.
The duty to fast depends upon being of adult age and of good health. Sick persons, pregnant, breast-feeding, or menstruating women, aged persons and travellers are exempted. However, there are patients who insist on fasting in Ramadan despite their condition because firstly, of the central significance and social role of fasting as a fundamental religious obligation. Through fulfilling this duty, Muslims participate in the social life of their religious community, which is crucial for their cultural identity formation and religious self-understanding.
“We meet each other, we support each other, and you find plates of food are being exchanged in the streets [laugh] from Muslim to non-Muslim. […] We all walk to the mosque and open fast there, […] We have lots of visitors I love Ramadan!”
Secondly, the main normative sources of Islam, the Koran and the traditions of the Prophet Muhammad, do not contain an explicit list of diseases and conditions prohibiting fasting and therefore it depends on the subjective assessment of the patient to decide which disease and which degree of illness requires them to abandon the fast.
It needs to be emphasised that there is also a spiritual/ psychological dimension to fasting. For instance, there is a strong desire among some Muslim people to insist on fasting despite being sick. Some people feel happier when they fast irrespective of their sickness.
Authors: Ilkilic, I. & Ertin, H.
Citation: Ilkilic, I. & Ertin, H. (2017). Ethical conflicts in the treatment of fasting Muslim patients with diabetes during Ramadan. Med Health Care and Philos, 20, 561-570. DOI 10.1007/s11019-017-9777-y.
Nursing Care of Pregnant Muslim Women during Ramadan
Pregnant Muslim women may choose to participate in fasting during the month of Ramadan. Their health care providers can help them make informed decisions to do so safely. Effective communication requires a basic understanding of Ramadan and the associated culture and of the potential motivations for women who choose to engage in fasting. Discussions both sensitive and mindful in nature can promote a stronger relationship between a woman and her LMC, as well as overall better health outcomes.
Health care providers should not assume that Muslim women who engage in fasting are aware of the rightful options offered by their faith; they should inform them of the risks and benefits of fasting and should be open to discussing possible options with them. In this way, LMCs can work with women if needed to find alternatives to fasting, such as postponing fasting until later in the pregnancy, or replacing fasting with service to the community.
It is important for LMCs to be aware of the potential complications secondary to fasting and be informed of assessment techniques that may help guide interventions and communication. LMCs and other clinicians who counsel pregnant Muslim women about fasting during Ramadan should offer culturally tailored patient education that includes recommendations for diet and information about the potential complications of fasting. Women should be advised to drink sufficient fluids and consume nutrient-dense foods, such as whole grains, during their predawn and evening meals.
Authors: Meyer, J., Pomeroy, M., Reid, D. & Zuniga, J.
Citation: Meyer, J., Pomeroy, M., Reid, D. & Zuniga, J. (2016). Nursing Care of Pregnant Muslim Women. Nursing for Women’s Health, 20 (5), 456-462.