Dubai: Ramadan is a time for physical and spiritual cleansing when people observe a dawn-to-sunset fast in the ninth month of the Islamic lunar calendar which is marked by piety, compassion and self-control.
While it is obligatory for every Muslim to fast, those who suffer from sickness and ill health are exempted. However, every true believer wants to offer this penitence to God and therefore those with special health conditions keen on fasting have to consult their physician who can advise them about best practices and important tips on how to manage their condition while observing the fast.
An important tip for those planning to undertake the fast, especially those with specific medical conditions like diabetes, hypertension, asthma, cardiovascular disease, pregnant women and those breastfeeding, is to acclimatise their bodies by eating lighter food, pushing back meal times and gently easing into fasting mode.
Diabetes
A metabolic disorder, diabetes affects blood glucose metabolism and requires close monitoring and a measured meal plan. People with both Type 1 (insulin dependent) and Type II diabetes (lifestyle-triggered that can put people on oral medication or insulin injections) can fast under supervision of their endocrinologist.
Dr Hamed Farooqi, head of Dubai Health Authority’s (DHA’s) Dubai Diabetic Centre, explained: “The ability to fast is based on both the complexity of the treatment plan as well as the level of control. Having said that, the ability to fast is certainly more difficult in type 1 diabetes given the total reliance on external insulin.”
The decision to fast during Ramadan depends on the severity of the disease, according to Dr Farooqi, as the patients range from those who control sugar through natural diet to those who require multiple injections of insulin or an insulin pump. “The health-care provider will make a decision in consultation with the patient, keeping in view the entire clinical profile.”
Altered blood glucose metabolism
Is it possible to alter meal times and maintain blood glucose levels? Can diabetics break down their insulin unit requirement to smaller doses to address meal times at suhour and iftar?
Dr Farooqi explains: “Mealtimes undergo radical change during Ramadan, particularly with regard to the suhour or predawn meal. However, the human body is quite resilient and responds well to this change. However, diabetics may have a limited ability to adapt. Therefore, dietary recommendations are critical in order to fast successfully during Ramadan.
Keep in mind:
“A continuous eating binge after sundown is not healthy for diabetics or non-diabetics. Therefore, matching insulin to an unusual eating pattern is not advisable. Instead, the main meal of the day is taken after sunset and the insulin dose is matched to the glucose load. Similarly, the predawn meal is covered for its carbohydrate content, keeping in mind the possibility that if excess insulin is taken, a low blood glucose reaction (hypoglycaemia) may occur,” said Dr Farooqui.
He advises diabetic patients to discuss the type and dosage of the medicine that the individual will take during fasting and tweak the pattern of taking medicine under medical guidance.
Diet
A healthy combination of all the major food groups, including proteins, carbohydrates and fats, is particularly essential during Ramadan, Dr Farooqi advises.
1) Foods with a high glycemic index (the rate at which sugar is released into the blood) such as white bread, sweets, fried food, lead to a rapid rise in glucose levels. Not recommended at iftar.
At suhour, more complex carbohydrates along with some fat is recommended to help maintain stable glucose concentration during the fasting hours. Multigrain breads, steel-cut oats porridge, fresh fruits, provide a sense of fullness as they are rich in fibre and nutrition.
For iftar, break the fast the traditional way with one or two dates and water. Drink plenty of water and sugar-free beverages but avoid caffeine as it can be dehydrating.
Diabetics must take special care to have enough liquids during suhour to keep them going though the day, Dr Farooqi cautions.
“It is essential to avoid fluid loss by limiting one’s exposure to heat. When the blood sugar levels rise, the body starts to flush it out by producing more urine. That needs water. Hence, drinking sugary drinks at suhour will lead to high blood sugar levels, followed by excessive urination in the morning hours and subsequent dehydration. Dehydration can lead to serious complications such as thrombosis or stroke,” Dr Farooqi says.
Warning:
Diabetics can suffer from either hyper- or hypoglycaemia or excessive sugar or low sugar levels. Dr Farooqi advises: “Generally, if blood glucose levels fall below 70mg/dl, the fast should be discontinued immediately. This is especially important if the person is on insulin or glucose-lowering tablets.
“The usual practice of consuming carbohydrates (15 grams) followed by a rechecking of blood glucose levels after 15 minutes should be followed. This should be repeated until blood glucose levels return to normal. Avoid overzealous correction as that would lead to hyperglycaemia (excessive sugar in the blood).
“Similarly, hyperglycaemia, such as glucose in excess of 300mg/dl, would require one to end their fast and resume their recommended medication regime to bring their glucose levels back to normal. Effective rehydration is essential in this situation.”
Best practice tip:
“Be proactive. Talk to your health-care provider ahead of time. Get a proper meal plan in addition to adjustment in the medication regime. This will allow you to focus on getting the maximum spiritual returns of this blessed month,” Dr Farooqi says.
Cardiovascular disease (CVD)
Patients with any heart conditions that come under the umbrella of cardio-vascular diseases can fast provided they are in a stable condition and under the guidance of a physician or heart specialist and taking regular medication.
Dr Stefan Manzel, interventional cardiologist and specialist in CVD at the German Heart Centre in Dubai Health Care City (DHCC), said: “CVD is characterised by a weak heart and danger of heart failure. So, anyone seeking to fast must get himself screened for any imminent heart issues such as pain or weakness. If everything is fine, a CVD patient can go ahead with the fast, but take it one day at a time.”
Diet:
Patients must gently ease themselves into the fasting routine by cutting out heavy food and caffeine some days before the fast and having several small meals throughout the day instead of three large meals.
Hydration: This is very important for patients with CVD as they take diuretics to flush out water from the body and avoid water retention as that can strain the heart. Not having water for long hours can result in dehydration and stress the kidneys and cause electrolyte imbalance in the blood, Dr Manzel warns,
Diet: During suhour have very light foods, with little or no oil, and have plenty of water. “Take 100ml of any fruit juice and dilute it with 400ml of water and have this during the predawn meal for nutrition-based hydration that will keep electrolyte balance in check,” he says. Other food groups to include during all meals, be it suhour or iftar, are those with dense nutrition such as high-fibre multigrain bread, oats porridge with low-fat milk, fresh fruits, oil-free meat and grilled chicken with small amounts of steamed brown rice. “The patient should make sure to include protein, carbohydrates and fats in the right amounts.”
It is important that instead of having one big meal after sunset, CVD patients can have several small portions of meals intermittently until they go to bed.
Medication: The patient who has medication in the morning can easily push it two hours earlier and have it during suhour and, if required, after iftar. But if the patient experiences any pain or discomfort, he must discontinue the fast on that day and have his medicines. It is advisable to take the fast one day at a time and be prepared to break it in case of a pain episode, Dr Manzel advises.
Exercise: CVD patients cannot indulge in exercise that increases the heart rate abnormally. Very light exercise during the fast is advised such as walking, stretching and yoga. “Exercise in the morning or evening before a big meal, but take care not to increase the heart rate too much and allow the blood vessels time to warm up.”
Best practice tip: While fasting CVD patients should check their weight and their skin tone every day. If the weight loss is more (between 2kg-4kg) and the skin is dry and wrinkled, then they can be sure it is water loss due to diuretics and they must have enough water. While it is important to get anything between six-eight hours of sleep, CVD patients must respond to the needs of the body. If they are tired and sleepy during the day, they should listen to the body and take rest.
Hypertension
Most studies to date indicate that people with mild to moderate hypertension that is stable and well controlled on oral antihypertensive agents administered once or twice can generally fast without any major problems. However, those with uncontrolled hypertension or complex regimes involving multiple medication taken throughout the day should refrain from fasting, Dr Farooqi warns.
Medication
Hypertensive patients can avoid excessive blood pressure fluctuations by ensuring that medication is taken as per the physician’s advice. In case of more complex regimes, the treating physician can help make the decision whether fasting is medically possible and how to adjust the timing of the prescribed medication.
Home blood pressure monitoring can serve as a useful means to monitor the level of blood pressure control. Ensure that a proper cuff is used and one is relaxed when the BP is monitored. These devices may not work if one has an irregular heart rate, Dr Farooqi points out.
Hydration
Proper hydration is essential. Dehydration can lead to low blood pressure as well as to thrombosis and strokes. Certain antihypertensive medication such as diuretics cause fluid loss and may aggravate the condition during Ramadan. As one has to refrain from drinking fluids during the day, the emphasis should be on avoiding fluid loss through excessive sweating and ensuring that they are on the right antihypertensive therapy that will not cause fluid loss.
Diet
Avoid drinks with high-salt or high-sugar content as they will lead to abnormal blood pressure levels through different mechanisms. Salty drinks will lead to high blood pressure while high-sugar drinks may lead to low blood pressure due to excessive fluid loss.
Light, low-fat meals such as steamed vegetables, grilled white meat, oil-free snacks of dense carbohydrates are advised. “Limit high-salt and high saturated fat diets. Increase intake of fresh fruits and vegetables. Choose wholegrain and low-fat dairy products, particularly for suhour.
The DASH diet (Dietary Approaches to Stop Hypertension) is a plant-focused diet, rich in fruits and vegetables, nuts, with low-fat and non-fat dairy, lean meat, fish, and poultry, mostly wholegrain, and heart-healthy fats,” Dr Farooqi says.
Exercise
Although a physical workout is an essential part of a healthy lifestyle, in the context of Ramadan in the middle of summer when the temperature is high with the inability to ingest fluids, exercising is not recommended during the day. Exercise should be deferred to the evening. The regime should keep in consideration the additional Taraweeh prayers as well, Dr Farooqi advises.
Rest
Hypertensive patients should take care that the interrupted circadian rhythms (waking up before dawn and sleeping late) do not affect their blood pressure.
“The recommended sleep is approximately eight hours. At the same time, the quality of sleep is also important. As the days are longer during summer, the night-time sleep may be impacted during Ramadan but generally people take time to sleep during the afternoon hours. In terms of the circadian rhythms, the impact can be kept to a minimum by ensuring that one goes to bed relatively early if good blood pressure control is an issue, “ Dr Farooqi says.
Best practice: Ramadan is the time for meditation and spiritual activity. Indeed, that helps. Contemplate fasting only if medically possible. Uncontrolled hypertension can lead to dangerous complications such as strokes and kidney damage. Almighty Allah does not wish us any harm and has mercifully allowed us exemption from fasting for medical reasons.
Pregnant women:
While expectant mothers can opt out of fasting, those who intend to undertake the fast need to take certain precautions. Dr Muna Tahlak, obstetrician and gynaecologist at DHA, said: “It is difficult for women to fast in the first trimester when they have morning sickness and in the last trimester when the baby presses against the vital organs in the abdomen making the woman breathless. Those in the second trimester usually find it easy to fast. But women in any trimester can fast under guidance from their gynaecologist and if they do not have any other health-related complex complaints.”
Diet
Special attention needs to be paid to the diet of a fasting pregnant woman as she is eating for two. So, she needs to take her prenatal multivitamin pills with her meals at suhour. These pills contain zinc, selenium, iron and other essential vitamins.
Hydration is very important for a pregnant woman as lack of water can induce uterine contractions. Besides this, pregnant women must include foods that maintain a proper potassium-sodium balance. They need to include foods such as bananas, kiwi fruit, coconut water, qamradeen and yoghurt during suhour, Dr Muna advises.
She added: “Expecting mothers should have high protein and dense carbohydrates such as harissa, tarid (stuffed vegetables with meat stew), or grilled chicken that will keep them full as they are slowly digested. They should avoid anything salty or fried that can make them feel thirsty during the day. The ideal weight gain throughout pregnancy should not exceed more than 15kg and the maximum weight gain happens after 28 weeks. An expectant mother should make sure to have small frequent bites after iftar that keeps her nutrition steady. After ending her fast with dates and buttermilk, she can have a light soup, then have a well-balanced dinner after a gap of an hour. She can have a post-midnight snack of a fruit, walnuts or labneh and then a suhour meal.”
Best practice: Get a lot of rest during the afternoon. Many patients say an hour’s afternoon nap helps them cope with fasting better.
Do not overeat when ending the fast. Have something light like a clear soup and let your body slowly adjust to food. It will help you digest it better and assimilate the nutrients better, Dr Muna says.
Lactating mothers:
Mothers who are breastfeeding need not fast as their child is dependent on their nutrition. But it is safe to fast during Ramadan if they consult their physician and pay attention to the nutrition and hydration needs of themselves and their babies.
Hydration: This is of utmost importance as lack of liquids in the body can reduce the production of milk and also impact the quality of the milk produced, keeping the baby hungry and irritated. Lactating mothers must make sure they have enough liquids during suhour and avoid food that causes gas as it can make the baby suffer from colic pain, Dr Muna cautions.
Diet:
- Plenty of liquids
- Coconut water
- Yoghurt
- Laban
- Clear soups
- Fruit juices
- Dense carbohydrates
High proteins during the predawn meal and during iftar. Avoid spicy and oily food as it can affect the quality of milk and do not forget your multivitamin pills.
Get plenty of rest and keep away from stress as that can affect the milk supply. Keep to normal routines of breastfeeding the baby throughout the day. Express extra milk in bottles but do not disturb your breastfeeding routine during the day, Dr Muna advises.
Best practice tip:
Lactating mothers can have powdered helba (fenugreek seeds). Traditionally, these seeds are known to stimulate milk production in women.
Hypothyroidism
People suffering from hypothyroidism (underproduction of thyroxine) in the thyroid glands in the throat that causes the metabolism to turn sluggish need to take specific medication on an empty stomach and can have anything to eat only after a half-hour gap. “Having thyroid medication in this manner is advised for better absorption of the pill into the body to stimulate thyroid production,’ Dr Ebrahim Enamin, endocrinologist at DHA, says. So, during Ramadan, thyroid patients who usually have their medication in the morning must change their pattern of taking the pill in the evening just as they break their fast. “Before suhour, they would not have an empty stomach as they might have had a post-midnight snack. So, it is better to have the medication just before having a meal at iftar. As soon as it is time to end the fast at sunset, a thyroid patient must first ingest his pill with a glass of water and desist from eating anything. He can offer prayers during that time and have his first bite after that so that it gives the all-important gap for the medicine to be absorbed by the body,” he advises.
