1. Shahid Athar, MD, FACP, FACE Author, “Islamic Perspective in Medicine” (ATP)

2. Ramadan Fasting and Muslim Patients

3. Abstract “ Fasting from dawn to dusk in the holy month of Ramadan for healthy adult Muslims has been ordained and physically sick Muslims are exempt from it. However many Muslims with mild to moderate Diabetes, Hypertension and other medical conditions do want to fast. The purpose of this presentation is make some recommendations as to how they can fast safely in light of research on fasting”

4. Quran 2:183 “ O you who believe! Fasting has been prescribed to you as it was prescribed to those before you so that you attain Taqwa (self restraint, God Awareness)”

5. Who Cannot Fast 1. Physically sick ( Quran 2: 184-185) 2. Traveler on a journey (above) 3. Women during menstruation 4. ? Pregnant and lactating women 5. pre pubertal children

6. Physiological Effects of Fasting On Calorie intake On fluid /water intake Effects on – Digestive System - Kidneys - Endocrine glands - Lipid Metabolism - Respiratory system - Neurological System

7. Uniqueness of Islamic Fasting It is a voluntary undertaking rather than being ordered by a physician There is no selective food intake i.e. protein only, juice only, fruit only, water only etc There is no total calorie malnutrition i.e. it not a semi starvation diet. An exercise in self discipline i.e. from constant nibbling, drinking, smoking etc Psychological effect and additional prayer

8. Effects of Fasting on Carbohydrate Metabolism 1. Slight fall in serum Glucose (to 60 mg) 2. Serum Insulin decreases due to 1 3. Serum Glucagon and Growth Hormone increases due to 1 4. Increase in sympathetic activity 5. Increase in liver Cyclic AMP due to 4

9. CHO Metabolism in Ramadan Slight decrease in first week then normalization by day 20 and some rise in the last week 22% children develop hypoglycemia (BG <40mg/dl) Increase Gluconeogenesis in liver

10. Fasting and Lipid Metabolism Decrease in both Total Cholesterol and Triglycerides in first few days then rise to pre fasting levels Increase in HDL-C Effects are variable according to quality and quantity of food consumed at Iftaar and Sahur

11. Endocrine functions in Fasting Fall in free T3 but rise in rT3 Slight fall in total T4 (due to fall in TBG) but normal freeT4 and TSH TSH response to TRH unchanged Serum Testosterone, LH, FSH may be normal or slightly low but GNRH response is normal Plasma Prolactin and PTH are normal

12. Renal Function in Fasting Urinary volume, osmolality, solute and electrolyte excretion remain normal Slight increase in BUN (insignificant) Increase in Uric acid (less in Ramadan fasting than in prolonged fasting)

13. Other Effects of Fasting Slight rise in Bilirubin but no change in SGOT or SGPT Fall in Gastric secretions No change in Heart rate and BP No change in Ca+ or Electrolytes No change in Hb, blood counts or Fe store

14. Other Effects of Fasting Weight loss of 1.7-3.8 Kg (obese lost more weight than non obese) Decrease in appetite due to ketosis and increase in Beta-endorphins Fewer suicide in Ramadan than in other months (reported in Jordan) No change in outcome of pregnancy or in birth weight in those who fasted and those who did not (reported in Gambia)

15. Patients who should not fast Patients who should not fast Diabetes Mellitus Type 1 Chronic Renal Failure including Renal Transplant and Nephrolithiasis Severe cardiac and pulmonary conditions G.I. Bleed and acute ulcers Severe Epilepsy Severe Migraine

16. General advice for those who fast Consult your (Muslim) doctor first Practice fasting in Shaban first With the approval of physician switch to either long acting or twice daily medication Elderly patients on NSAID should have frequent monitoring of renal functions Anticoagulant and Antiepileptic medications should be given at night.

17. Fasting for NIDDM (ref:3) Benefits of Fasting in Ramadan A. Better control of Diabetes B. Better control of Hypertension C. Better control of Lipid D. 5-10 lb weight loss Thus Fasting is advised for stable NIDDM

18. NIDDM- Recommendations Control your Diabetes for two months prior to Ramadan bringing HbA1c to < 8 Discontinue Metformin a week before fast Drugs like Actos, Avandia, Glucotol XL are safer than Diabeta, Amyril, and Starlix Continue Diabetic diet in Iftaar and Sahur

19. Fasting for those on Insulin Consult your Diabetologist (Muslim) first Discontinue Insulin mixtures such as 70/30, 75/25, or Regular Insulin If on NPH then reduce the total dose by 20% and take 2/3 at Iftaar and 1/3 at Sahur If on Lantus then reduce by 20% and take at night -Titrate by 2 units ( BG 120-140) Take 4-6 units of fast acting Insulin such as Novolog or Humalog before two meals

20. Monitoring for IDDM Finger stick BG after Iftaar and before sahur BG if feeling bad (low) Terminate fast if BS below 60 or over 400 No exercise before Iftaar Drink plenty of water at iftaar and Sahur

21. Questions from Muslims Fasting and Pregnancy Fasting and Nursing Blood draw during Fasting Medications during Fasting -Tablets, inhalers, patches, injections Exercise / Sports during Fasting Mouth washes and gums during Fasting

22. References Azizi, F et all” Evaluation of blood hormones and constituents in Ramadan” JIMA, Nov. 1987 Soliman, N “ Effects of Fasting during Ramadan” JIMA Nov 1987 Athar, Shahid “Management of NIDDM during Islamic Fasting in Ramadan :JIMA vol 27 1995 Athar, Shahid “Fasting for Medical Patients- suggested guidelines” Islamic Horizon, May ’85 Athar, Shahid “Therapeutic Benefits of Ramadan Fasting” Islamic Horizon: May’ 84

23. Some Parting Thoughts “Fasting is for Me and I (Allah) only will reward it” (Hadith Qudsi) “While fasting, if one does not give up falsehood in words and actions, then Allah has no need of him giving up food and drink (saying of Prophet Muhammad-pbuh) HAVE A BLESSED RAMADAN

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25. Salaam from Sheikh Deedat