Medical Aspects Of Islamic Fasting
Shahid Athar, M.D.
There are close to 900 million Muslims in the world, including about 8 million in the North America. The majority of them observe total fasting (no food or water) between dawn to sunset in the month of Ramadan. They do so not for losing weight or any medical benefit, but for them it is ordained in their Holy Book Quran which says.
"O you who believe! Fasting is prescribed to you, as it was prescribed for those before you (i.e. Jews, & Christians) so that you may (learn) self-restraint." 2:183
According to Islamic Laws, children below 12, sick patients, travelers, and women who are menstruating or nursing a baby are exempt from fasting. In addition to staying away from food or water for the whole day, they are asked to stay away from sex, smoking or misconduct during the period of fast. In addition, they are encouraged to do more acts of piety i.e.prayer, charity, or reading Quran during this month.
Food is needed by the body to provide energy for immediate use by burning up carbohydrates, that is, sugar. Excess of carbohydrates which cannot be used is stored up as fat tissue in muscles, and as glycogen in liver for future use. Insulin, a hormone from the pancreas, lowers blood sugar and diverts it to other forms of energy storage, that is, glycogen. To be effective, insulin has to be bound to binding sites could receptor. obese people lack receptor; therefore, they cannot utilize their insulin. This may lead to glucose intolerance.
When one fasts (or decreases carbohydrate intake drastically), it lowers his blood glucose and Insulin level. This causes breakdown of glycogen from liver to provide glucose for energy need and breakdown of fat from adipose tissue to provide for energy needs.
On the basis of human physiology described above, semi-starvation (ketogenic diets (I -5) have been devised for effective weight control. These diets provide calculated amount of protein in divided doses with plenty of water, multi-vitamins, etc. These effectively lower weight, blood sugar, but because of their side effects, should be used only under supervision of physicians.
Total fasting reduces or eliminates hunger and causes rapid weight loss. In 1975, Allan Cott in his "Fasting as a Way of life" noted that "fasting brings a wholesome physiological rest for the digestive tract and central nervous system and normalizes metabolism." It must be pointed out, however, that there are also many averse effects of total fasting. That includes hypokalemia and cardiac arrythmia associated with low calorie starvation diets used in unsupervised manner.
<center> Studies On Islamic Fasting
</center> Dr. Soliman, from the University Hospital, Amman, Jordan (ref. 8) has reported that during the month of Ramadan 1404 AH (June-July, 1984 AD) healthy Muslim volunteers; 42 males and 26 females, ranging in age from 15-64 and 16-28 years respectively were studied. They were weighed and their blood levels of cortisol, testosterone, Na, K, urea, glucose, total cholesterol, high density lipoprotein (HDL), low density lipoprotein (LDL), triglycerides (TG) and serum osmolality were measured at the beginning and at the end of Ramadan.There was significant loss of weight in males form a mean of 73.8 +- 6.2 kg 72.0+- 7.1 kg (P less than 0.01) and in females from 55.2 +- 4.8 to 54.6 +- 4.2 kg (P less than 0.05). Blood glucose levels rose in males from 77.7 +- 23.6 mg/dl to 90.2 mg/dl (P less than 0.05) and in females from 76.0 +- 7 mg/dl to 84.5 +- I 1.1 mg/dl (P less than 0.002). All other parameters did not show significant changes.
Dr. F. Azizi and his associates (ref.9) from the University of Medical sciences, Tehran, Iran has reported the following. serum levels of glucose, bilirubin, calcium, phosphorous, protein, albumin, FSH, LH, testosterone, prolactin, TSH, TI, TI, and T uptake, as well as prolactin and TSH responses to TRH were evaluated in group of nine healthy men before and on the 1Oth, 20th and 29th days of Ramadan. Mean body weight decreased from 65.4 +- 9.1 to 61.6 +- 9.0 kg at 29th day. Serum glucose decreased from 82 +- 4 mg/dl on the 10th day, and increased thereafter (76 +- 3 and 84 +- 5 on the 20th and 29th days of fasting respectively). Serum bilirubin increased from 0.56 +- 0.17 to 1.43 +- 52 mg/dl on the 10th day, and decreased thereafter (I. I.+- 0.4 on the 20th and 29th days.) All Changes returned to basal values four weeks after fasting. There were no significant changes in serum levels of Ca, P, protein, albumin, and any of measured hormones. Prolactin and TSH responses to TRH were also unaltered. He concluded that:: (1) intermittent abstinence from food and drink for 17 hours a day for 29 days does not alter male reproductive hormones, hypothalainic-pituitary-thyroid axis or peripheral metabolism of thyroid hormones and (2) physicians caring for Muslims should be aware of changes of glucose and bilirubin during Ramadan.
Therefore it is concluded from the above two studies that Islamic fasting does not cause any adverse medical effect and may have some beneficial effect on weight and lipid metabolism.
<center>Why Islamic Fasting Is Different Than Other Types of Fasting (ref. 7)
</center> The Islamic fast, is different from the above "Diet Plans". It has beneficial features of both plans. Its unique medical benefits are due to the following factors :
I . As compared to other diet plans, in fasting during Ramadan, there is no malnutrition or inadequate calorie intake since there is no restriction on the type or amount of food intake during Iftaar or Sahar. This was confirmed by M.M.Hussaini (ref. 6) during Ramadan 1974 when he conducted dietary analysis of Muslim students at the University of North Dakota State University at Fargo. He concluded that calorie intake of Muslim students during fasting was at two thirds of NCR- RDA. 2. Fasting, in Ramadan is voluntarily undertaken. It is not a prescribed imposition from a physician. In the hypothalamus part of the brain there is a center called "lipostat" which controls the body mass. When severe and rapid weight loss is achieved by starvation diet, the center does not recognize this as normal and, therefore re-programs itself to cause weight gain rapidly once the person goes off the starvation diet. So the only effective way of losing weight is slow, self-controlled, and gradual weight loss by modifying our behavior, and the attitude about eating while eliminating excess food. Ramadan is a month of self-regulation and self-training if terms of food intake thereby causing hopefully, a permanent change in lipostat reading.
3. In Islamic fasting, we are not subjected to a diet of selective food only (i.e. protein only, fruits only etc). An carry breakfast, before dawn is taken and then at sunset fast is broken with something sweet i.e. dates, fruits, juices to warrant any hypoglycemia followed by a regular dinner later on.
4. Additional prayers are prescribed after the dinner, which helps metabolize the food. Using a calorie counter, I counted the amount of calories burnt during extra prayer called Traveeh. It amounted to 200 calories. Islamic prayer called Salat uses all the muscles and joints and can be placed in the category of a mild exercise in terms of caloric out put.
5. Ramadan fasting is actually an exercise in self discipline. For those who are a chain smoker, or nibble food constantly, or drink coffee every hour, it is a good way to break the habit, hoping that the effect will continue after the month is over.
6. Psychological effect of Ramadan fasting are also well observed by the description of people who fast. They describe a feeling of inner peace and tranquility. The prophet has advised them "If one slanders you or aggresses against you, tell them I am fasting". Thus personal hostility during the month is minimal. Crime rate in muslim countries fall during this month.
It is my experience that within the first few days of Ramadan, I begin to feel better even before losing, a singIe pound. I work more and pray more; physical stamina and mental alertness improve. As I have my own lab in the office, I usually check my chemistry, that is, blood glucose, cholesterol, triglyceride before the commencement of Ramadan and at its end. I note marked improvement at the end. As I am not overweight, thank God, weight loss is minimal. The few pounds I lose, I regain soon after. Fasting in Raniadan will be a great blessing for the overweight whether with or without mild diabetes (type II). It benefits those also who are given to smoking or nibbling. They can rid themselves of these addictions in this month.
<center>Fasting For Medical Patients: Suggested Guide-line (ref. 10)
</center> As mentioned earlier, patients are exempt from fasting. But some, for whatever reasons, do decide to observe fasting. For physicians treating Muslim patients, the following guidelines are suggested.
a. Diabetic Patients: Diabetics who are controlled by diet alone can fast and hopefully with weight reduction, their diabetes may even be cured or at least improved. Diabetics who are taking oral hypoglycemia agents like Orinase along with the diet should exercise extreme caution if they decide to fast. They should reduce their dose to one-third, and take the drug not in the morning, but with Iftar in the evening. If they develop low blood sugar symptoms in the day time, they should break the fast immediately. Diabetics taking insulin should not fast. If they do, at their own risk, they should do so under close supervision and make drastic changes in the insulin dose. For example, eliminate regular insulin altogether and take only NPH in divided doses after Iftar or before Sahar. Diabetics, if they fast, should still take a diabetic diet during Iftar, Sahar and dinner. The sweet snacks common in Ramadan are not good for their disease. they should check their blood sugar before breakfast and after ending their fast.
b. Hypertensive or Cardiac Patients: Those who have mild to moderate high blood pressure along with being overweight should be encouraged to fast, since fasting may help to lower their blood pressure. They should see their physician to adjust medicines. for example, the dose of water pill (diuretic) should be reduced for fear of dehydration and long acting agents like Inderal LA or Tenormin can be given once a day before Sahar. Those with severe hypertension or heart diseases should not fast at all.
c. Those with Migrain Headache: Even in tension headache, dehydration, or low blood sugar will aggravate the symptoms, but in migraine during fasting, there is an increase in blood free fatty acids, which will directly affect the severity or precipitation of migraine through release of catecholamines. Patients with migraines are advised not to fast.
d. Pregnant Women (Normal Pregnancy): This is not an easy situation. Pregnancy is not a medical illness, therefore, the same exemption does not apply. There is no mention of such exemption in Quran.However, the Prophet said the pregnant and nursing women do not fast. This is in line with God not wanting anyone, even a small fetus, to suffer. There is no way of knowing, the damage to the unborn child until the delivery, and that might be too late. In my humble opinion, during the first and third trimester (three months) women should not fast. If however, Ramadan happens to come during the second trimester (4th-6th months) of pregnancy, a women may elect to fast provided that (1) her own health is good, and (2) it is done with the permission of her obstetrician and under close supervision. The possible damage to the fetus may not be from malnutrition provided the Iftar and Sahar are adequate, but from dehydration, from prolonged (10-14 hours) abstinence from water.
Therefore it is recommended that Muslim patients if they do fast. do so under medical supervision.