: An Overview for Primary Care Providers Considerations when caring for Muslim patients who fast for Ramadan

Brittany Heck, MS4 May 31, 2019

Introduction The Rules of Ramadan What is Ramadan? Overview In the Islamic religion, there are five Ramadan starts with the first pillars, or duties, for its practitioners. crescent of a new moon and ends with Eid These include professing one’s faith, al-Fitr (Festival of Breaking Fast). Each praying five times a day, making day begins with a smaller meal called charitable donations, doing the suhoor and then the fast is broken in the pilgrimage to Mecca, and during evening with a rich, celebratory meal Ramadan. Many consider Ramadan to be called . Sunni Muslims break the fast the most sacred month of the year. It at sunset when the sun is no longer presents an opportunity to strengthen visible over the horizon, whereas Shias relationships with oneself, with family, wait until the sky is completely dark. and with God.2 It promotes renewed Standard greetings for people celebrating spirituality, introspection and discipline, Ramadan include “Ramadan kareem” and while also encouraging appreciation, “Ramadan Mubarak,” which mean “have a compassion, and altruism.8,14 generous Ramadan” and “have a blessed Ramadan occurs in the ninth month Ramadan,” respectively.9 of the , but because it is based on a lunar calendar, which consists Obligations and Exemptions of 354 days, the exact timing of Ramadan According to the , fasting is an varies. Those who participate must obligation for all adult Muslims of sound abstain from food, drink, intimacy, mind and body. Muslim children are profanity, and other acts that nullify the introduced to fasting by incremental fast from dawn to sunset. The Quran steps (a few half days to a few full days to specifies which acts are impermissible all days), and typically begin after puberty and which groups of people are exempt or age 10.2 Those who cannot safely fast, from the fast.2 including travelers, the elderly, the Depending on its timing in the year mentally or developmentally disabled, and the location in the world, some and the acutely or chronically ill, are patients may be fasting for up to 20 hours. excused from fasting.9 Women who are This extended period without food, water, menstruating or having postpartum and medications may pose a serious bleeding are not permitted to participate health risk to patients with certain in fasting (or prayers) as this is believed medical conditions. With over 1.6 billion to violate their purity and invalidate the Muslims worldwide, all primary care fast. Women who are pregnant or providers should be aware of the health may opt in or out of fasting considerations for their Muslim patients and are encouraged to excuse themselves during Ramadan.9 if they have concerns over their health or their child’s.13 However, while it provides

1 these exemptions, those excused are fasting hours or until after Ramadan if obligated to make up the fast at a later possible. Table 1 summarizes the date or feed one poor person for each day interventions that do and do not missed (this is called paying “fidiya”).2, 9 invalidate the fast according to the Islamic Fiqh Council and the Standing Acts that Do and Do Not Invalidate the Committee for Academic Research and Fast Issuing Fatwas (Fataawa al-Lajnah ad- While the Quran clearly elucidates Daa’imah), an Islamic organization that some actions that will render the fast provides consensus on Islamic invalid, newer treatments and procedures jurisprudence.1,8 have caused some controversy among Nonetheless, although scholars Muslim scholars. In general, anything that have declared an action as permissible, enters or exits the body including the patient may not be aware or may not intentional eating, drinking, or vomiting agree. A study of 201 practicing Muslims will invalidate the fast. This includes and 10 religious leaders in Guinea found interventions such as intravenous that religious leaders were 30% more therapies (IV saline and parenteral likely to believe an intervention nutrition), blood transfusions, and (vaccinations and blood draws) was dialysis as they provide nourishment to acceptable than the laymen. 3 The lack of the body. As previously mentioned, this consensus among religious scholars and also includes sexual activity, smoking, among practitioners as well as the lack of oral medications, and even chewing gum. cultural awareness and sensitivity among Muslims are additionally encouraged to medical professionals puts Muslim refrain from gossip and profanity.1,4,9 patients at risk of having complications With other interventions, Muslim related to the fast. When in doubt, scholars disagree due to different providers may encourage their patients to understandings of the Islamic texts. For consult their local religious leader. example, the Islamic Fiqh Council, an affiliate of the League, Implications for General issued a fatwa that ear and nasal drops do Practice not break the fast, so long as nothing Things to Consider in Primary Care reaches the stomach. However, different As previously mentioned, Ramadan scholars believe these measures do break is one of the most important tenets of 1 the fast regardless. Interventions such as . Fasting is a religious duty, a oxygen and anesthetics, inhalers and bonding experience with family, and is nebulizers, blood draws, rectal viewed positively. Breaking the fast is suppositories, enemas, bladder irrigation, usually accompanied by big familial pessaries, biopsies, intravenous contrast, celebrations.2 Moreover, completing creams or patches for transdermal missed fasts at another time is more administration of medication, and difficult without communal support.1,13 injections that are not alternatives to food Because of the great religious and drink (antibiotics, insulin, significance and the considerable vaccinations) are generally regarded as associated social pressures, it is permissible while fasting, but it is recommended to postpone these for non-

2 important for providers to consider that medical recommendations.1 Some practicing Muslims may choose to fast patients may decide to continue with the despite having medical conditions that fast despite being exempt from it. Others excuse them from fasting and despite may be more amenable to breaking the understanding their increased risk of fast for a particular procedure. Many may medical complications. Providers should not know exactly which interventions are also be cognizant that studies have shown permissible and which will break their that patients who fast have a greater fast.1, 12 propensity to self-discontinue Furthermore, providers could even medications, decrease glucose utilize the discipline involved in partaking monitoring, limit vaccinations and blood in Ramadan and encourage their patients sampling, or be otherwise nonadherent to to take the opportunity to make (and medical advice during Ramadan.1, 3 maintain) healthy lifestyle changes to lose On the other hand, providers must weight and quit smoking.14 Studies have be mindful that, as with any patient, shown that, although patients lose weight Muslim patients are unique and may not and lower their total cholesterol and LDL all approach Ramadan in the same way. levels while fasting, most return to their Variations in spirituality, religiosity, and pre-Ramadan measurements within a few personal beliefs will affect patients’ health weeks.16, 17 Appointments before and behaviors and their engagement with after Ramadan could be helpful in aiding

3 patients to continue the progress made conditions have regimens that have been during this period. previously suggested and studied for patients during Ramadan.7 Management of the Muslim Patient during Ramadan Advice for common conditions DIABETES General advice for those who fast One of the chronic illnesses that It is recommended that all Muslim poses the most concern during Ramadan patients who wish to fast have a pre- is diabetes. Fasting goes directly against Ramadan medical evaluation ideally 6-8 the typical dietary advice for diabetics of weeks prior. While patients with chronic eating multiple small meals throughout medical diseases will understandably the day. As such, fasting has been shown require a more in depth consideration of to increase the episodes of dehydration, how to minimize their risk while fasting, hypoglycemia, hyperglycemia, diabetic even relatively healthy patients should be ketoacidosis, hyperosmolar advised on approaches to fasting safely. hyperglycemia state, and deep vein This includes preventing dehydration by thrombosis.3 During Ramadan, there is a drinking plenty of fluids during non-fast 4.7 fold increase and a 7.5 fold increase in hours and avoiding caffeinated drinks, episodes of severe hypoglycemia for Type eating food rich in fiber and low in salt, 1 and Type 2 diabetics, respectively, and a fat, and sugar, and saving exercise for 5 fold increase in hyperglycemic events in 1 after iftar. It is equally important to Type 2 diabetics.8 This risk is discuss with patients the medical compounded by the fact that many indications for breaking the fast and Muslim diabetics will forgo with blood seeking assistance. glucose monitoring over concern that doing so invalidates their fast. Advice on managing medications Nevertheless, 40-50 million patients with Like primary care providers, diabetes fast during Ramadan. By pharmacists should also be aware of subtype, about 50% of those with type 1 Ramadan and the limitations it imposes diabetes and between 80-90% of those on medication regimens. Unfortunately, with type 2 participate in fasting.1,7,9 studies show that pharmacists in non- The will to fast is not limited to adult predominately Muslim countries diabetics. A study of children with type 1 (specifically the United States, Canada, diabetes found that a majority wanted to and Australia) perceive little need to fast and 75% were encouraged to do so counsel patients on medication changes by their parents. They found whereas a majority of acceptable because they would just break their counterparts in countries like Egypt the fast if any complications arose, which and Saudi Arabia (predominately Muslim) they did. Throughout Ramadan, 52% of will routinely adjust medication regimens these children had at least one episode of during Ramadan. Some culturally hypoglycemia, 29% had at least one sensitive changes could include changing episode of hyperglycemia, and one child dosing frequency to once or twice daily, was admitted for diabetic ketoacidosis.3 changing to long acting formulations or Despite knowing this, children and adults choosing a different medication with diabetes continue to be encouraged administration. Certain medical and to participate in fasting.

4 Muslim scholars and medical The highest two risk categories are providers recommend against fasting for recommended to abstain from fasting.8 those with type 1 and uncontrolled type 2 That said, providers should be aware that diabetes. It may be safe for patients with their Muslim patients with diabetes will controlled type 2 diabetes to participate often choose to fast during Ramadan in fasting as long as they seek medical regardless of recommendations and advice prior.3,14 The International should educate accordingly. Diabetes Federation collaborated with the Diabetic patients who wish to fast Diabetes and Ramadan International should definitely meet with their Alliance (IDF-DAR) to create practical physician prior to Ramadan. Clinicians guidelines to aid providers in supporting can then assess their risk, modify their Muslim patients with diabetes. medications as needed, and educate on These are available to download at their safe fasting practices.1,8 First and websites.6,15 This group also provided foremost, providers should explain the specific criteria to stratify diabetic warning signs for the common patients into three different risk complications, such as hypoglycemia and categories that has been approved by the diabetic ketoacidosis, and stress the Mufti of Egypt, the highest religious importance of breaking the fast and regulatory authority in Egypt (Table 2). seeking medical attention should they

5 have symptoms. Blood glucose values less daily may need the predawn dose than 70 or greater than 300 are reduced to avoid hypoglycemia with less indications for breaking the fast. food consumed throughout the day. Other Providers should also explain that blood oral agents can be given once daily with glucose monitoring does not break the the evening meal. Thiazolidinediones, fast and should encourage patients to DPP-4 inhibitors, and short acting oral continue to check regularly throughout insulin secretagogues do not require the day.1,14 Figure 1 depicts how often adjustment as they carry a low risk of type 2 diabetics should check their hypoglycemia. Patients on long acting glucose levels.8 In between sunset and insulin should decrease their total dose dawn, people with diabetes should eat by 20%.8,9 With thoughtful medication well-portioned, nutritious meals for iftar and lifestyle adjustments, patients with and suhoor to avoid hyperglycemia and diabetes can reduce the risk of should additionally eat two to three small complications while fasting during meals in between these.1 Ramadan, as long as providers remember Ramadan-focused diabetes to be sensitive to the cultural context of educational programs have been shown their Muslim patients. to be effective in significantly reducing the incidence of hypoglycemic events.8 AND BREASTFEEDING The IDF-DAR created Ramadan-specific Providers should recommend nutrition therapy for different countries against fasting in pregnant and and in different languages for patient and breastfeeding women for the safety of provider use that are available online.15 both the woman and her child.9 The data Diabetic medication regimens will on the effects of fasting during Ramadan often need adjustments to account for the on mother and child is conflicted. For the altered dietary habits. Metformin can be mother, there has been found to be an dosed twice a day, with a third of the total increased risk of hyperemesis gravidarum daily dose taken at the predawn meal and and increased maternal cortisol level two thirds taken at the larger evening when fasting. An increase in urinary tract meal. Sulfonylureas that are dosed twice infections is also common for fasting mothers due to insufficient fluid intake. For the fetus, most studies show that the risk of low birth weight, intrauterine growth restriction, and preterm birth is not statistically higher in pregnant women who fast.11 One study found that fasting mothers actually had a lower rate of Cesarean section. Another study found a reduction in fetal biophysical profiles in fasting mothers. One interesting finding came from a study that followed children into adulthood and found that Muslim adults who had their fetal period during Ramadan were thinner and shorter than Muslim adults who did not. This difference was not seen in non-Muslim

6 adults.11,16 As for breastfeeding, fasting hypertensive medications taken once has been shown to decrease breastmilk daily with a meal is the best strategy. supply, requiring mothers to use more Diuretics are not recommended, given the formula.1,11 risk of dehydration. Studies have proven However, studies show 70-90% of patients on oral anticoagulants like pregnant women observe the fast.8 Some warfarin may continue these medications may feel obligated to fast due to personal safely while fasting. Muslim scholars have spiritual reasons or even social pressure deemed permissible nitroglycerin tablets from family that may be difficult to placed under the tongue for treatment of understand from those outside of the angina pectoris. Those with dyslipidemia culture.13 There are also differences to who have been stable on a statin may consider between each patient. American- continue without complication, but born Muslims have been shown to be less statins should not be started right before likely to fast than their foreign-born Ramadan. On the other hand, individuals counterparts. Additionally multiparous with uncontrolled hypertension, unstable mothers are more likely to fast compared angina, decompensated heart failure, to primigravidas.11 The bottom line is if a recent cardiac surgery or myocardial pregnant or breastfeeding woman wishes infarction should not fast. As always, to participate in Ramadan, that is her physicians should recommended a low choice and providers should be salt, low fat, healthy diet, even during supportive and give patients appropriate Ramadan.1,10 advice. Recommendations include stressing adequate hydration, GASTROINTESTINAL consumption of nutritious foods during In general, for gastrointestinal (GI) non-fasting hours, and precautions diseases, it depends on the patient and on against excessive daytime activity. the disease. Individuals with active peptic Women should also be advised of warning ulcers are recommended to not fast, but signs to look for that should prompt those with nonactive ulcers stably on breaking the fast and seeking medical proton pump inhibitors can fast safely. attention such as decreased fetal People with inflammatory bowel diseases movement, extreme fatigue or dizziness or chronic hepatitis are also cleared to and severe nausea with vomiting.3,10,11 fast. Medications for diseases like H. pylori may be postponed until after Ramadan to Advice by organ system ensure proper adherence or may be CARDIOVASCULAR dosed differently to account for fasting Multiple systematic reviews and restrictions.1,16 meta-analyses have shown that Providers should be aware that participating in Ramadan does not fasting patients commonly complain of increase the risk of developing acute new onset dyspepsia with symptoms cardiovascular (CV) events. In addition, it including bloating, indigestion, and is generally safe for people with most CV heartburn. This is especially prevalent in diseases to fast. Patients with controlled patients who eat excessive amounts or high blood pressure should meet with extremely rich meals for iftar and suhoor. their primary care providers before Recommendations to eat moderately and Ramadan to review medications and avoid trigger foods should help adjust as needed. Long acting anti- symptoms.1

7 RENAL The general recommendation for There is a paucity of studies on the patients with renal issues is to drink effect of fasting on patients with chronic sufficient amounts of water during non- . A few indicate that the fasting hours to pass about two liters of fluid restriction involved in fasting may urine in a 24-hour cycle to reduce adverse be harmful to the kidney.1 Other studies events. Patients with a history of have shown an increase in the incidence urolithiasis may also limit intake of of kidney stones during Ramadan, but the vitamin C, sodium, and oxalate.1,10 evidence is inconclusive. A 2014 systematic review involved studies of Conclusion patients with CKD on hemodialysis, The goal of healthcare providers peritoneal dialysis (PD), and should always be to provide holistic, pharmacological treatment and showed compassionate care. Primary care no severe effects while fasting as long as providers especially are presented with they followed dietary and therapeutic the duty to care for their patients within recommendations and did not have other their greater socioeconomic, religious, comorbidities like diabetes. Since dialysis geographic, and cultural context. For most provides a type of nourishment to the Muslim patients, a basic understanding of body, it invalidates the fasting if done the tenets and importance of Ramadan during fasting hours. Therefore, dialysis could be very meaningful and patients who wish to fast may choose to instrumental in building rapport and in fast on non-dialysis days or choose creating a shared mental model. This between two regimens of PD: modified could help in maintaining the patient’s continuous ambulatory PD (three health goals by maximizing adherence to exchanges during the night with medications and lifestyle modifications. icodextrin infusion) or continuous cycling It is important that the providers peritoneal dialysis (one exchange over consider the impact of fasting during the night). If the creatinine increases by Ramadan when making the plan for their 30% above the baseline, patients should patient. Clinicians should discuss their break the fast. Moreover, patients should reservations on fasting with patients who be educated on warning symptoms such have certain medical conditions and as an increase in weight, swelling, suggest they honor Ramadan in other shortness of breath or weakness and ways, but understand that patients may avoid high-potassium, high phosphorous still choose to participate in Ramadan. As 5 foods when breaking fast. such, providers can then suggest Patients with a prior kidney appropriate medications and regimens to transplant who have stable graft function maximize adherence, advise patients to may fast without concern for hydrate and eat recommended foods, and complication. Studies show that there is educate them on what symptoms to look no difference in levels of creatinine, urea, for that should prompt them to break the uric acid, sodium, potassium, or fast. Above all, providers should empower bicarbonate in the urine between pre- their Muslim patients with the confidence and post-Ramadan. Furthermore, and knowledge to optimize their fasting immunosuppressant medications can be with shared decision making.14 1 divided into twice daily dosing.

8 Resources

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