Ramadan and Health Issues

Ramadan and Health Issues 

With the fasting day lasting from sunrise to sunset, the body's energy can be replaced in the two meals a day. It's important to get in food from all the five major food groups, and this will provide an easier transition from using fat to burn energy as opposed to glucose. 

This means weight can be lost, muscles can be preserved, cholesterol levels can fall, with more control being had over diabetes and blood pressure. 

As well as this, a few days into Ramadan, the body begins to adjust to its new eating and drinking pattern as higher levels of endorphins appear in the blood, making fasters more alert, happier, and giving an overall feeling of better mental health. 

On the whole, Muslims who do choose to fast should avoid overly greasy and deep- fried foods, instead opting for baking, grilling, and shallow frying their two meals a day. 

Breaking the fast at iftar with dates and sweet, milky drinks is common in many households which provides a much- needed energy boost after the fasting day. Drinking plenty of water for rehydration will ensure the body is kept revitalised. 

You should have a balanced diet,with the right proportion of carbohydrate, fat, and protein. 

How to stay hydrated during Ramadan? 
While keeping fast people are restrained from drinking water as well. This becomes an issue to many people who generally dislike water, and the intake of water drastically reduces. This is the main reason behind the increased cramping and muscle pain that is often experienced in the month of Ramadan. To avoid this, one needs to consume at least eight glasses of water throught the day after the fast ends. 

Excercise in Ramadan 
The holy month of Ramadan often makes people who fast completely exhausted by the strain of fasting. However, completely giving up daily workout is the worst thing anyone can do in the month of Ramadan. While following a complete workout plan may be unrealistic for many. It is important to go for walks and stretch regularly even in the month of Ramadan. Having a target number of steps and meeting it post- iftar will be ideal to help in the digestion of the food and make space for dinner as well. It is important to exercise regularly during Ramadan to keep the entire body's function normal while fasting. 

Ramadan in special situations: 
People with type-1 diabetes should not usually fast, but people with type-2 diabetes on insulin should be able to. They may need to adjust the dose of their insulin, or their insulin type may need to be changed. 
People with uncontrolled migraine should not fast. But managing migraine is possible with the right medicine and certain lifestyle changes. 
Blood Pressure: 
People with well controlled high blood pressure can fast. Doctor may advise to change the medicine to help take tablets outside fasting times. Someone with low blood pressure who is otherwise healthy may fast. They must ensure they drink enough fluid and have enough salt. 
Someone receiving a blood transfusion is advised not to fast on medical ground. They may fast on the days when no transfusions are required. 
Taking tablets break the fast. But injections, patches, eardrops, and eyedrops don't break the fast as they are not considered to be food and drink. 
There's medical evidence to show that fasting in pregnancy isn't a good idea. If a pregnant woman feels strong and healthy enough to fast, especially during the early part of the pregnancy, she may do so. 
If she does not feel well enough to fast, Islamic law gives her clear permission not to, and to make up the missed fasts later. If she is unable to do this, she must perform fidyah, a method of compensation for a missed act of worship, such as paying for someone to be fed. 
Breast Feeding: 
Islamic law says a breasrfeeding mother does not have to fast. Missed fasts must be compensated for by fasting at a later date, or fidyah, once brestfeeding has stopped. 
Smoking is bad for health and Ramadan is a great opportunity to drop unhealthy habits, 
including smoking. 
Muslim experts have differing opinions on this issue. Some say using an asthma inhaler isn't the same as eating or drinking and is therefore permitted during fasting. In their view, people with asthma can fast and use their inhalers whenever they need to. 
But other scholars say the inhaler provides small amount of liquid medicine to the lungs, so it breaks the fast. They say people with poor control of their asthma must n't fast until good control is achieved. 
Some people with asthma may opt for longer acting inhalers so they can fast. 
A bath or shower, or swimming, has no effect on the fast. No water should be swallowed during any of these activities, as that would break the fast. 
You could become very dehydrated if you don't drink enough water before the fast. Poor hydration can be made worse by weather conditions and even everyday activities like walking to work or housework. 
If you produce very little or no urine, feel disoriented and confused, or faint as a result of dehydration, you must stop fasting and have a drink of water or other fluid. If a fast is broken, it will need to be compensated for by fasting at a later date. 
People on dialysis must n't fast and should perform fidyah, such as paying for someone to be feed. 
If you are overweight, it can be an opportunity to lose weight- provided you eat healthily when you break the fast. 
Source of energy during fast: 
The changes that happen in the body during a fast depend on the length of the continuous fast. 
The body enters into a fasting state eight hours or so after the last meal, when the gut finishes absorbing nutrients from the food. 
In the normal state, body glucose, which is stored in the liver and muscles, is the body's main source of energy. 
During a fast, this store of glucose is used up first to provide energy. Later in the fast, once the glucose runs out, fat becomes the next source of energy for the body. 
When a prolonged fast of many days or weeks, the body starts using protein and breaking down protein for energy. This is the tecnical description of what's commoly known as " starvation".  
You are unlikely to reach the starvation stage during Ramadan, because the fast is broken daily. 
Gentle transition from glucose to fat:  
As the Ramadan fast only lasts from dawn till dusk, the body's energy can be replaced in the pre- dawn and dusk meals. This provides a gentle transition from using glucose as the main source of energy to using fat, and prevents the breakdown of muscle for protein. 
The use of fat for energy helps weight loss. It preserves the muscles and eventually reduces your cholesterol level. In addition, weight loss results in better control of diabetes and reduces blood pressure. 
After a few days of fast, higher levels of endorphins appear in the blood, making you more alert and giving an overall feeling of general mental wellbeing. 
A balanced food and fluid intake is important between fasts. The kidneys are very efficient at maintaining the body's water and salts, but these can be lost through sweating. 
To prevent muscle breakdown, meals must contain enough energy food, such as carbohydrates and some fat. 
How to fast safely during Ramadan:  
The way to approach your diet during fasting is similar to the way you should be eating outside Ramadan. 
You should have a balanced diet, with the right proportion of carbs, fat and protein. 
If you are not careful, food eaten during the pre- dawn and dusk meals can cause some weight gain. 
Approaching the fast with discipline, otherwise an opportunity to lose weight and be healthier could be wasted. 
Aim for a balanced diet:  
Those obsering the fast should have at least two meals a day: the pre- dawn meal ( suhor ) and a meal at dusk ( Iftar ). 
Your food intake should be simple and not differ too much from your normal diet. 
It should contain foods from all the major food groups: 
* fruit and vegetables 
* bread, cereals and potatoes 
* meat, fish or alternatives 
* milk and dairy foods 
* foods containing fat and sugars 
Try to limit the amount of sugary foods you eat and instead include healthier sources of carbohydrate in your diet, such as wholegrains, potatoes, vegetables, fruits, legumes, and lower fat dairy products. 
Foods high in fibre can help to keep your bowels healthy and add bulk to your meal, helping you to feel full. 
These include:  
* fruits 
* vegetables 
* pulses 
* starchy foods ( especially wholegrain varieties ) 
It's also worth avoiding caffeine- based drinks such as tea, coffee and cola. Caffeine is a diuretic and stimulates faster water loss through urination. 
Wholesome foods:  
Suhoor, the pre- dawn meal, should be a wholesome, moderate meal that's filling and provides enough energy for many hours. 
" slow digesting food like pitta bread, salad, cereal ( especially oats ) or toast provide a constant release of energy." 
" It is important to have some fluids with vitamins, such as fruit juice or fruit. Some people have isotonic drinks to replace any lost salts". 
It's customary for Muslims to break the fast ( Iftar ) with some dates, in accordance with the prophetic traditions. 
Fruit juices will also have a similar revitalising effect. 
Foods to avoid:  
* deep- fried foods- such as pakoras, samosas and fried dumplings. 
* high- sugar and high- fat foods- including sweets such as gulab jamun, rasgulla and balushahi. 
* high- fat cooked foods- such as parathas, oily curries and greasy pastries. 
Healthy alternatives:  
* baked samosas and boiled dumplings 
* chapatti's made without oil 
* baked or grilled meat and chicken 
* homemade pastry using just a single layer 
* milk- based sweets and puddings, such as rasmalai and barfee 
Effects on health of fluid restriction during fasting in Ramadan: 
Fasting during Ramadan is partial because the abstention from food, fluid, tobacco and caffeine is from sunrise to sunset. During the daylight hours of Ramadan fasting, practising Muslims are undoubtedly dehydrating, but it is not clear whether they are chronically hypohydrated during the month of Ramadan. 
The annual Ramadan fast is not obligatory for all Muslims, for there are several categories of healthy people and patients who are exempt ( prepubertal children; the insane ), or who can postpone the Ramadan fast ( the acutely ill, women during menstruation, pregnancy, post- childbirth confinement and lactation; travellers ) or who are unable to fast ( the chronically ill; the frail elderly ), but who are encouraged to feed a needy individual during the month of Ramadan. 
Energy balance:  
Generally, meal frequency is reduced during Ramadan fasting, which it has been found often leads to reduced energy intake and loss of body mass and body fat. In general, any loss in body mass is usually relatively small and it may also be attributed to a decrease of glycogen- bound water stores, extracellular volume contraction secondary to a lower sodium intake, and a moderate degree of hypohydration with little loss of body tissue. 
Psychosomatic alterations:  
There is decrease in subjective feelings of alertness, and an increase in lethargy and irritability during daytime fasting. Cognitive function has also been shown to be decreased, although this is not a universal finding. Part of this mood change is caused by alterations in normal circadian rhythms, with individuals becoming more active through the evening and night and sleep deprivation. However, the effects of rectrictions on smoking tobacco, ingesting caffeine and energy and fluid intake must also contribute to this general feeling. 
A frequently cited problem of Ramadan fasting is an increased incidence of headaches. Irritable- related stress was considered to be the main factor leading to tension headaches, while Ramadan fasting appeared as the prime precipitating factor for migraines. Headache frequency increased with duration of the fast and affected mainly those individuals prone to having headaches. Tension headaches accounted for the majority of cases. Although lack of sleep, hypoglycemia, and dehydration might have caused some these incidents, caffeine withdrawal appeared to be the main contributory factor. The number of headache sufferers increased in direct relation to the duration of the fast. Headaches were rated as being mild to moderate in intensity and individuals who were prone to headaches were more likely to develop fasting- induced headaches. 
A reduction in energy or fluid intake by the pregnant mother may produce detrimental effects on foetal growth. Women in late pregnancy showed the phenomenon of ' accelerated starvation' during Ramadan, characterized by low serum levels of glucose and alanine, and especially high level of free fatty acids and beta- hydroxybutyrate. The additional metabolic stress of Ramadan fasting in pregnancy and during lactation has the potential to cause retardation of foetal and neonatal growth and development, respectively. In several countries fasting by breastfeeding mothers of infants is common during Ramadan. Fasting cause changes in milk osmolality, and lactose and potassium concentrations indicative of a marked disturbance of milk synthesis. 
Owing to the relationship between fasting and hypoglycemia, diabetics who undertake Ramadan fasting have been considered as a highly vulnerable group. 
Body mass tended to decrease over the period of Ramadan, while serum creatinine levels increased, inferring that overall the subjects were hypohydrated at the end of Ramadan. 
Several other studies have shown stable or a slight improvement in fasting blood sugar during the Ramadan fast. Other studies have proposed that improvement in glycemic control can only be detected in patients who show a decrease in body mass caused by the intermittent Ramadan fast. While the general consensus from the clinical studies undertaken appears to be that most established NIDDM patients can cope with the intermittent fasting during Ramadan, medical practioners must make their patients aware of the potential hazards involved and should consider the use of longer acting drugs during fasting. 
Acute coronary heart disease:  
There appears to be no obvious increase in acute coronary heart disease events associated with Ramadan. The fast of Ramadan has several benefits in reducing the likelihood of cardiovascular disease. Ramadan fasting has been shown to increase HDL cholesterol, while either lowering the LDL cholesterol or not affecting the levels of other cholesterol fractions. 
Peptic ulcer complications:  
A slight but significantly increased rate of peptic ulcer complications was observed during Ramadan. 
Intermittent dehydration:  
During the daytime hours of Ramadan fasting, practicing Muslims are unduobtedly dehydrating at a rate that is determined by the loss of body water minus the amount of metabolic water that is produced over this period. 
Water deprivation is fuctionally charaterised by maximum urine concentration. Urinary osmolality is higher during Ramadan than either before or after Ramadan. During Ramadan, effective water coservation is both by maximum urinary concentration and a decreased obligatory urine output. Daytime urine osmolality tended to increase progressively throughout the month of intermittent fasting. 
Muslims fasting for 12-14 h, there was a significant increase in hematocrit ( +11% ), serum albumin ( + 4% ) and serum creatinine ( +12% ), indicating hypohydration due to water deprivation. An increase in serum urea and increases in serum sodium and chloride are also found. A significant increase in serum osmolality, sodium and bicarbonate was observed only in a group of fasting Muslims with sedentary lifestyles, but not in a comparable group of physically active Muslims. The likely higher fluid turnover of the active group allowed more precise regulation of the body fluids than that of the sedentary gruop. 
Decreases in daily total fluid intake ( in the form of beverages, preformed water in food and the water of oxidation of the diet ) or increases in water losses if not adequately corrected obviously lead to dehydration. The average daily water turnover rate is approximately 2-3 L in healthy humans living normally in temperate environment conditions. Augmenting the daily fluid intake will speed the  rate of water turnover as urine volume increases, while exercise of sufficient intensity and duration will promote faster water turnover even in a cool ambient conditions, and exposure to a hot environment can also accelerate sweating and raise the rate of water turnover. In most situations where water turnover rate is altered, the total body water content was conserved. Total bory water content was conserved during Ramadan although daily water turnover was reduced. The decrease in water turnover appeared to be due to a reduction in fluid intake, but euhydration was maintained by a drop in nonrenal losses. Water turnover in hot desert coditions can be similar to that occuring in cooler environments if individuals are relatively inactive and they seek shade. 
Most Muslims with a predominantly sedentary occupation have few problems or relevant clinical symptoms connected with Ramadan fasting. Ramadan fasting leads to impairment in muscular performance and to a decrease in orthostatic tolerance. In those Muslims with psychosomatic complaints or headaches during Ramadan, intermittent dehydration may be a more important pathogenic factor than intermittent energy restriction. However, if fasting is extended ( e.g., up to 18 h ) on a daily basis and work is physically demanding, or has to carried out in a hot environment, complaints of tiredness, dizziness and nausea may become so predominant that both fasting and working have to stop to allow the individual to recover. 
Chronic hypohydration:  
An acute decrease in total body water content is the most reliable measure of hypohydration. Theoretically, a cumulative negative water balance of more than 3% of total body water is indicative of hypohydration. In an early study ( Muazzam & Khaleque, 1959 ), a body mass loss over the month of Ramadan of 1.4 kg was reported and this loss was equated with a drop in 24 h urinary volume during this period. However, the mean urinary output only drpped from 1.4 L/d before Ramadan to 1.2 L/d during Ramadan, and this lower excretion rate was established by day 10 of the fast before there was any sign of body mass loss. At the end of the fasting month, the mean daytime urine osmolality was about maximum, however, the urine passed through the night was fairly dilute. This suggests that there was compensation for daytime dehydration by increased drinking during the night, which prevented the individuals from becoming chronically dehydrated. The majority of the body mass loss was due to reductions in adipose tissue, as a consequence of a decrease in energy intake. Both the lactating and nonlactating women undertaking the intermittent fast of Ramadan developed a distinct acute dehydration before breaking the fast each day. 
* people think that fasting means starvation, but that does not happen until someone does not eat for four consecutive days. Fasting improves brain function and mood, increases vigilance and mental clarity. It also allows the gut to clean chemicals that accumulate. That does not happen often because when we eat, we interfere with that function. 
* intermittent fasting when done in tandem with diet change, it spurs weight loss, increases mental wellbeing, and removes toxins in the body. Limiting food intake in this manner also lowers cholesterol levels. 
* some experts go further in saying that Muslims who participate in Ramadan grow to understand the importance of water, using that to quence their thirst during the breaking of fast at sunset. Night prayers- also known as tarawih- also provide an opportunity for some physical activity. Such changes pose long- term health benefits, the most of significant being the avoidance of diabetes, heart disease, cancer, and other ailments. 
* Full day fasts, during which athlets abstain from eating for 24 hours, can also help the body in recovering from small injuries and joint pain. 
* when people fast, they go a long time during the day without eating. It is a cleansing that reduces calorie intake and that of junk food. There is no time to do mindless snacking. The idea is to not overindulge in food. 
Health issues and benefits: 
Ramadan can, surprisingly, have many health benefits. 
Despite potentially feeling some heartburn, irritability, dehydration, and a decline in concentration levels- which are expected- successful fasting can be done during Ramadan. 

The lack of food and water causes increased irritibility, changes in mood, and a lack of concentration. You may feel headachy, light- headed and lethargic. 
The performance of the athlets deteriorate as the month went on, despite training taking place after the evening meal. This is because of disturbed sleeping cycles, dehydration, and the new pattern of eating. 
Your body clock affects a whole lot of functions, such as body temperature. It's not just to do with physical activity, it is also an internal mechanism. During a fast you take energy in at night, when you normally are slowing down. If you fast, you have to accept that there will be a deterioration of performance, not just for athlets, but for all workers. 
Restricting what you eat can have a positive effect on your mind, by creating a break in your normal routine- as long as you are undertaking if with that aim in mind. 
Most people exercise less in Ramadan and so need fewer calories than normal. 
Indigenous groups ate in accordance of the body's circadian rhythms- physical, mental, and behavioural changes that follow a 24- hour cycle and respond to natural light and darkness. Disruption to this flow can induce weight gain and slow thinking- similar to what happens to people who experience jetlog. 

Prof. Dr. A. K. M. Aminul Hoque 
Formerly Prof. of Medicine 
Dhaka Medical College