Caring for patients during Ramadan

Every year millions of Muslims around the world observe Ramadan. Typically in April or May, this holy month includes regular prayer and daily fasting. Muslims abstain from food and drink from sunrise to sundown and meals will often include specific rituals and customary foods. Dietitians working with patients during Ramadan may struggle to provide interventions that meet nutrition needs while also respecting religious practices.

How can Ramadan impact nutrition intake?

“Time-restricted fasting” during Ramadan can affect nutrient and energy intake, however, there is mixed evidence demonstrating a reduction in caloric intake during this month. Although meal frequency is often decreased, possible overconsumption at meals surrounding fasting may mitigate caloric deficit. Care should be given to carefully assess patient food preferences during this time as diverse practices across cultures can ultimately impact their dietary pattern changes.

Meals surrounding Ramadan fast:

• Iftar: First meal to break the fast at sundown. This meal usually includes all food groups, but contains a wide variety and quantity of carbohydrates. Traditionally, it is begun by consuming dates and is the larger of the two meals surrounding the fast.
• Suhoor: Last meal prior to sunrise. Protein-rich foods are offered here along with water to hydrate for the day of fasting ahead.

Strategies for working with Ramadan patients

There are certain groups that are considered exempt from fasting: the elderly, pregnant, nursing, and the ill. However, some Muslims who fall into one or more of these categories may choose to fast anyway. If this is the case, here are some considerations for working with these patients:

Diabetes

Patients with Type 1 diabetes are at an increased risk for severe hypoglycemia and diabetic ketoacidosis. Patients on sulfonylureas and insulin are at highest risk for adverse events, such as hypoglycemia, so regular glucose monitoring, patient education, and adjustment of treatment regimens should ideally occur prior to Ramadan. It may be medically prudent for these patients not to undertake fasting, however, it is an important personal decision for some patients.

Key nutritional considerations for these patients:

1. Keep a log of glucose levels and hypoglycemic events.
2. Avoid skipping Suhoor or pre-dawn meal.
3. Save physical activity and exercise for non-fasting hours.
4. Maintain body weight through Ramadan.
5. Avoid large consumption of carbohydrates and fats at Iftar.

Overweight/Obese

Ramadan fasting is often used as a lifestyle modifier for the overweight and obese as the reduction in caloric intake and meal frequency is expected to lead to weight loss. Numerous studies have demonstrated significant reductions in bodyweight in obese individuals, however, these results are often temporary with subjects returning to pre-Ramadan weight two to five weeks following the Ramadan period. If using as a lifestyle modifier, these patients should aim to maintain the weight lost during Ramadan.

Despite commonly seen weight reductions in overweight or obese individuals, there is mixed evidence to suggest temporary or long-lasting changes in other cardiometabolic risk factors such as LDL, HDL, and triglyceride levels.

General Population

Unlike overweight or obese individuals, those with a healthy body mass index (BMI) may see long-lasting benefits to their lipid profiles following Ramadan fasting. Significant differences in HDL and LDL cholesterol levels could suggest a potential favorable impact on lipid profiles following this fasting period. Note that commonly seen changes in types of foods consumed and decreased cholesterol and saturated fat intake could ultimately be influencing these changes.

Key nutritional considerations for these patients:

1. Maintain body weight through Ramadan.
2. Save fluids for after meal consumption (to maximize caloric intake and hydration status).
3. Eat every two to three hours during fed hours (if possible), not just Iftar and Suhoor meals.
4. Optimize caloric and nutrient-dense food consumption.

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References:

Osman, F., Haldar, Su., Henry, C.J., Effects of Time-Restricted Feeing during Ramadan on Dietary Intake, Body Composition and Metabolic Outcomes. (2020). Nutrients. 12(2478): 1-25.  

Shatila, H., Baroudi, M., El Sayed Ahmed, R., et al. Impact of Ramadan Fasting on Dietary Intakes Among Healthy Adults: A Year-Round Comparative Study. (2021). Frontiers in Nutrition. 8: 1-12. 

Grindrod, K., Alsabbagh, W. Managing medications during Ramadan fasting. (2017). CPJ/RPC. 150(3): 1-4.  

Al-Arouj, M., Assad-Khalil, S., Buse, J., et al. Recommendations for Management of Diabetes During Ramadan. (2010). Diabetes Care. 33(8): 1895-1902.  

Ibrahim, M., Abu Al Magd, M., Annabi, F.A., et al. Recommendations for management of diabetes during Ramadan: update 2015. (2015). BMJ Open Diabetes Res Care. 3(1).