Ramadan and Chronic diseases

Ramadan; “unique metabolic model.”
Usama Ragab Youssif (Msc.)
Assistant Lecturer of Internal Medicine
Tuesday, 16 May 2017

Agenda
• Introduction and facts.
• Physiological effects of Ramadan Fasting.
• Fasting in Health.
• Fasting in disease.
 Fasting and thyroid.
 Fasting and kidneys
 Fasting and heart.
 Fasting and GIT.
• Fasting and medicines.
• Final bottom line and take home message.

‫الرحيم‬‫الرحمن‬‫هللا‬ ‫بسم‬
‫ا‬َ‫ي‬‫ا‬َ‫ه‬ُّ‫ي‬َ‫أ‬ََ‫ين‬ِ‫ذ‬َّ‫ال‬‫وا‬ُ‫ن‬َ‫م‬‫آ‬ََ‫ب‬ِ‫ت‬ُ‫ك‬َُ‫م‬ُ‫ك‬ْ‫ي‬َ‫ل‬َ‫ع‬َُ‫م‬‫ا‬َ‫ي‬ ِ‫الص‬‫ا‬َ‫م‬َ‫ك‬ََ‫ب‬ِ‫ت‬ُ‫ك‬‫ى‬َ‫ل‬َ‫ع‬‫ا‬ََ‫ين‬ِ‫ذ‬َّ‫ل‬‫ن‬ِ‫م‬
َْ‫م‬ُ‫ك‬ِ‫ل‬ْ‫ب‬َ‫ق‬َْ‫م‬ُ‫ك‬َّ‫ل‬َ‫ع‬َ‫ل‬ََ‫ون‬ُ‫ق‬َّ‫ت‬َ‫ت‬(183)‫ا‬ً‫م‬‫َّا‬‫ي‬َ‫أ‬َ‫ات‬َ‫د‬‫ُو‬‫د‬ْ‫ع‬َّ‫م‬ََ‫ن‬َ‫م‬َ‫ف‬ََ‫ان‬َ‫ك‬‫م‬ُ‫ك‬‫ن‬ِ‫م‬ًَ‫ض‬‫ي‬ ِ‫ر‬َّ‫م‬‫ا‬
َْ‫و‬َ‫أ‬َ‫ى‬َ‫ل‬َ‫ع‬َ‫ر‬َ‫ف‬َ‫س‬َ‫ة‬َّ‫د‬ِ‫ع‬َ‫ف‬َْ‫ن‬ِ‫م‬َ‫َّام‬‫ي‬َ‫أ‬َُ‫أ‬ََ‫َر‬‫خ‬َ‫ى‬َ‫ل‬َ‫ع‬ َ‫و‬ََ‫ين‬ِ‫ذ‬َّ‫ال‬‫و‬ُ‫ق‬‫ي‬ِ‫ط‬ُ‫ي‬َُ‫ه‬َ‫ن‬َ‫ة‬َ‫ي‬ْ‫د‬ِ‫ف‬َُ‫م‬‫ا‬َ‫ع‬َ‫ط‬
َ‫ين‬ِ‫ك‬ْ‫س‬ِ‫م‬َۖ‫ن‬َ‫م‬َ‫ف‬ََ‫ع‬ َّ‫و‬َ‫ط‬َ‫ت‬‫ا‬ً‫ْر‬‫ي‬َ‫خ‬ََ‫و‬ُ‫ه‬َ‫ف‬ََ‫خ‬َ‫ْر‬‫ي‬َُ‫ه‬َّ‫ل‬َ‫ن‬َ‫أ‬ َ‫و‬‫وا‬ُ‫م‬‫و‬ُ‫ص‬َ‫ت‬ََ‫خ‬َ‫ْر‬‫ي‬َْ‫م‬ُ‫ك‬َّ‫ل‬َۖ‫ن‬ِ‫إ‬
َْ‫م‬ُ‫ت‬‫ن‬ُ‫ك‬ََ‫ون‬ُ‫م‬َ‫ل‬ْ‫ع‬َ‫ت‬(184)َُ‫ر‬ْ‫ه‬َ‫ش‬ََ‫ان‬َ‫ض‬َ‫م‬َ‫ر‬‫ي‬ِ‫ذ‬َّ‫ال‬ََ‫ل‬ ِ‫نز‬ُ‫أ‬َِ‫ه‬‫ي‬ِ‫ف‬َُ‫آن‬ ْ‫ر‬ُ‫ق‬ْ‫ال‬‫ًى‬‫د‬ُ‫ه‬
َِ‫اس‬َّ‫ن‬‫ل‬ِ‫ل‬َ‫َات‬‫ن‬ِ‫ي‬َ‫ب‬ َ‫و‬ََ‫ن‬ِ‫م‬َ‫ى‬َ‫د‬ُ‫ه‬ْ‫ال‬َْ‫ال‬ َ‫و‬َِ‫ان‬َ‫ق‬ ْ‫ر‬ُ‫ف‬َ‫ن‬َ‫م‬َ‫ف‬ََ‫د‬ِ‫ه‬َ‫ش‬َُ‫م‬ُ‫ك‬‫ن‬ِ‫م‬‫ا‬ََ‫ر‬ْ‫ه‬َّ‫ش‬‫ل‬َُ‫ه‬ْ‫م‬ُ‫ص‬َ‫ي‬ْ‫ل‬َ‫ف‬َۖ
‫ن‬َ‫م‬ َ‫و‬ََ‫ان‬َ‫ك‬‫ا‬ً‫ض‬‫ي‬ ِ‫ر‬َ‫م‬َْ‫و‬َ‫أ‬َ‫ى‬َ‫ل‬َ‫ع‬َ‫ر‬َ‫ف‬َ‫س‬َِ‫ع‬َ‫ف‬َ‫ة‬َّ‫د‬َْ‫ن‬ِ‫م‬َ‫َّام‬‫ي‬َ‫أ‬ََ‫َر‬‫خ‬ُ‫أ‬ََُۗ‫ي‬َُ‫د‬‫ي‬ ِ‫ر‬َُ َّ‫اّلل‬َُ‫م‬ُ‫ك‬ِ‫ب‬
ََ‫ر‬ْ‫س‬ُ‫ي‬ْ‫ال‬ََ‫ل‬ َ‫و‬َُ‫د‬‫ي‬ ِ‫ر‬ُ‫ي‬َُ‫م‬ُ‫ك‬ِ‫ب‬ََ‫ر‬ْ‫س‬ُ‫ع‬ْ‫ال‬َِ‫ل‬ َ‫و‬‫وا‬ُ‫ل‬ِ‫م‬ْ‫ك‬ُ‫ت‬ََ‫ة‬َّ‫د‬ِ‫ع‬ْ‫ال‬َِ‫ب‬َ‫ك‬ُ‫ت‬ِ‫ل‬ َ‫و‬‫وا‬ُ‫ر‬ََ َّ‫اّلل‬َ‫ى‬َ‫ل‬َ‫ع‬‫ا‬َ‫م‬
َْ‫م‬ُ‫ك‬‫ا‬َ‫د‬َ‫ه‬َْ‫م‬ُ‫ك‬َّ‫ل‬َ‫ع‬َ‫ل‬ َ‫و‬ََ‫ون‬ُ‫ر‬ُ‫ك‬ْ‫ش‬َ‫ت‬(185)
‫البقرة‬ ‫سورة‬

Who must fast?
•‫كل‬ ‫على‬ ‫تعالى‬ ‫هللا‬ ‫فرضه‬ ‫رمضان‬ ‫صوم‬:
1-‫مسلم‬.
2-‫بالغ،َفالَيجبَعلىَالصبي‬.
3-‫عاقل،َفالَيجبَعلىَالمجنون‬.
4-‫قادرَعلىَالصوم،َفالَيجبَعلىَالمريضَالذيَيزيدَال‬َ‫صوم‬
‫رؤه‬ُ‫ب‬َ‫مرضه،َأوَيؤخر‬.
5-‫مقيم،َغيرَمسافر‬.
6-‫سالمَمنَالموانع،َأيَمنَالحيضَوالنفاس‬.

In 2009, Islam making up 23% of the world population
of 6.8 billion, and is growing by ∼3% per year

Fast Facts
• Ramadan in the Islamic calendar is 9th lunar
months and the start of the islamic year
advances 11 days each year compared with
the seasonal year.
• Ramadan occurs at different times of the
seasonal year.
• Ramadan occurs in a different season every 9
years.

Fast Facts (cont.)
• What is different?
 Eating pattern.
 Amount of food.
 Night time eating.
 Day time sedentary life.
• Abstinence of what? is it selective fasting?
 Food.
 Water.
 Smoking.
 Oral medication.
 IV fluids & nutrients.

Fasting means abstinence
X
To stop eating, drinking and sexual activity
from dawn until dusk
XSmoking is also prohibited during fasting !
X

Exemption
• Upon reaching puberty, all healthy Muslims
are required to partake in the fast.
• Individuals who are sick, traveling, pregnant,
breast-feeding, menstruating, or debilitated
are exempt from fasting.
• However, many Muslims who are eligible for
exemption choose to fast nonetheless.
Trepanowski and Bloomer Nutrition Journal 2010, 9:57

The truth
• Muslims consume a greater variety of foods
during Ramadan compared with the rest of
the year.
• Also, sugary foods and drinks are consumed
more frequently during Ramadan.
Am J Clin Nutr 1988, 48:1197-1210.
Am J Clin Nutr 1982, 36:350-353.

1- On Calorie intake
• Regarding diet, energy intake during Ramadan has
been reported to increase in Saudi Muslims
and decrease in Indian Muslims; these discrepant findings
are believed to be due to the differences in food
choices between the groups.
Am J Clin Nutr 1995, 62:302-307.

1- Calorie intake
(cont.)

Counterregulatory hormones (stress) will increase thus
stimulating both gluconeogenesis and ketogenesis
Reduced insulin levels

Response of the body to fasting
•Reduced insulin level enhances glycogenolysis
and prevents hypoglycemia.
•Moreover, this process is followed by elevated
levels of glucagon, growth hormone, and
catecholamines, which are involved in the
stimulation of gluconeogenesis and
ketogenesis.

2- 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

3- Fasting and
plasma lipids

4- 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

Many Confounders??
• To summarize, little consensus exists regarding the
effects of Ramadan fasting on the majority of health
related outcomes.
• Many of the discrepancies regarding findings are
likely due to:
 Differences between studies in daily
fasting time
 Smoking in non fasting time
 Drug consumption
 Eating habits.

Optimal timing for the ingestion of thyroid
hormone during Ramadan
• There are many factor to be in mind:
 gastric motility greatly impaired with excess fast.
 heavy meals
 circadian rhythms alteration, and
 effect of deiodinase activity.
• So, it is better to take levothyroxin an hour before
Sohor or at bed time away from any medication.

Optimal timing for the ingestion of anit-thyroid
drugs during Ramadan
• Propylthiouracil has a limitation during Ramadan due
to its required dosing of every 4–6 h.
• The other most commonly used anti-thyroid drug
“methimazole” has a fairly long duration of action,
and can be taken at any time of the day in a single or
divided doses.

Thyroid Final Bottom line
• Hypothyroid patients can take their thyroxine at
bedtime easily (but there should be an interval of
minimum 2 hours since the last meal).
• Hyperthyroid patients, the preferred oral antithyroid
treatment is methimazole, which can be taken once
or twice daily in Ramadan easily.
• Patients with mild to moderate symptoms of
hyperthyroidism can fast safely.

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)
Ibnosina Journal of Medicine and Biomedical Sciences2.5 (2010): 240-257

Kidney disease & Risk of hypoglycemia

RecommendationIssue
-concentration of immunosuppressive drugs
tends to remain stable
-No kidney loss has been documented.
-One author: cyclosporine toxicity, acute
rejection episodes, and urinary infections.
Ramadan and kidney transplant (463
patients)
-does not seem to deteriorate health.
-any renal changes are fully reversible after
10 days from the end of the fasting.
Ramadan and urolithiasis (1,262 subjects)
-Existing data in the literature are scarce
and give inconclusive results.
-No severe adverse effects have been
recorded, apart from one study (Al-
Muhanna).
-Fasting on non-dialysis days is probably
safe and that dietary advice in fasting
patients assumes increasing importance*.
Ramadan and chronic kidney disease (140
subjects) 40 on hemodialysis, 18 on
peritoneal dialysis (PD), 15 on predialysis,
67 on pharmacological treatment.
*Ibnosina Journal of Medicine and Biomedical Sciences2.5 (2010): 240-257

• Patients suffering from acute tubular necrosis, polyuria (urine
volume ≥2.5 L/day), uncontrolled or poorly controlled diabetes
mellitus and insipidus or other dysmetabolic disorders,
hypertension, angina, postural hypotension, acute infections,
significant co-morbidities (such as cardiovascular disorders and
chronic liver disease) leading to marked limitations and
amendments of daily activities
• History of noncompliance and adherence to therapy, dietary
and drugs modifications.
Who should not fast??

Clinical recommendations for patients willing
to fast
•Patients should attend regular follow-up every 1-2
weeks, before, during and after Ramadan.
•Patients should take regularly their treatment twice
daily (with suhoor and Iftar respectively); if not
possible shouldn’t fast.

to fast (cont.)
•They should break the fasting if the plasma creatinine
increases by the 30% above the baseline values
and/or if you observe clinical symptoms due to
changes in serum potassium and sodium.
•Body weight, blood pressure, biochemical parameters
such as fluid and electrolytes should be regularly
checked

to fast (cont.)
•They should avoid high potassium and phosphorous
diet (such as dates, apricots, fried food, nuts, cheese,
soft juices and drinks, tea, coffee).
•If they have a tendency to hyperkalemia, they should
take some calcium resonium powder (30 g/die with
lactulose once a day).
•Rehydrate vs. dehydrate vs. overhydrate.

Fasting not eating??!!
•Under normal circumstances, fasting (not
eating) is the normal state of feeding and the
postprandial state is the temporary state.
•There is a reduction in the secretions
and slowing in the GIT motility.

Fasting and common GI disorders (cont.)
J Fasting Health. 2017; 5(1): 20-23.

1- Gastro-Esophageal Reflux Disease
• Gastro-esophageal Reflux disease is higher during
Ramadan fasting.
• Eating too fast without chewing or chewing with
mouth open, smoking at Iftar and Sohar, drinking too
much of carbonated and caffeinated beverages, such
as cola, coffee and tea and eating fatty and spicy
food.

1- Gastro-Esophageal Reflux Disease (cont.)
• Diet should contain a lower fat content and
the meals are made smaller in size.
• If erosive disease is evident by endoscopy, treatment
should be given in the form of proton pump
inhibitors (PPI’s) at iftar and suhour.
• (NERD) or GERD diagnosed by symptoms only,
a single daily dose of PPI should be
adequate before Iftar.

2- Bowel diseases
• IBD?? Which phase determine your response:
 Active = full nutrition support.
 Quiescent = fast and divide drugs at Iftar and
suhor.
• Fasting will be helpful for IBS.

Changes in liver function tests during Ramadan
fasting
• Liver glycogen content is decreased by
glycogenolysis.
• Fasting hyperbilirubinemia: occurs in healthy
individuals
but remember Gilbert’s syndrome.
• No significant changes in ALT, AST, protein, albumin
in any of the studies in normal

Fasting in chronic liver diseases
• Patients suffering from cirrhosis should be
assessed individually.
• Patients with decompensated cirrhosis should be
advised against fasting.
X
X

Final bottom line for liver & GI disorder in
Ramadan
•Most mild and stable GI conditions do not
constitute a reasonable cause for avoiding fasting.
•1Avoidance of over-eating, 2eating low fat food,
3drinking plenty of water, and 4adjusting previous
medications to once or twice daily regimes to meet
the timing of Iftar & Suhoor.

Fasting and heart
• No clear scientific consensus on its effects on
cardiovascular disease.
• Risk factors are modified (improved).
• Stable remain stable*
 Previous controlled attacks.
 Predictable stable angina.
 Early stage of heart failure.
 Properly controlled heart rhythms
• Hypertension is probably more better controlled
(possibly due to lack of fluid).

Modification of CV risk?
• Studies have shown improvement in LDL and 30-
40% increase in HDL Cholesterol levels.
• Triglyceride level is variable depending on dietary
habits of the local population. (This is not a trend)
• There is improvement in blood glucose and ? HbA1C
• On an average there is 1.7 to 3.8 kgs of weight
reduction for those who are overweight or obese.

Fasting and Cardiovascular Health
• 465 outpatients with stable heart disease had no increase in
hospitalization in Ramadan.
• Hospitalization for heart failure, stroke, acute coronary events
did not increase in Ramadan.
• A change in circadian variation of cardiac events:
• Less at 5 – 8 am, 11% vs 19%
• More at 5 – 6 pm, 11% vs 6%
• More at 3 – 4 am, 11% vs 7%
• More strokes between noon - 6 pm vs 6 am to noon.
Ozkan et al. J Int Med Res. 37:1988, 2009
Chong VH. Singapore Med J. 50:619, 2009

Unstable CVD
• Recent ‘Heart Attack’
• Unstable Angina
• Decompensated Heart Failure
• Uncontrolled severe Hypertension
• Active and symptomatic Heart Rhythm problem
requiring active teatment.

Medications During Ramadan (Cardio)

Selected drugs with circadian variation in pharmaco-
kinetics and pharmaco-dynamics

Commonly encountered drug-food interactions and
recommendations

DIET
• Complex carbohydrate : whole grain
• Avoid food with High Glycemic Index (GI)
• Proteins are essential.
• Some amount of fat is essential
• Vitamins from vegetables and fruits.
• Drink plenty of water.
• Avoid carbonated and caffeinated drinks.

People who are exempted from fasting
Aged* Sick**
Pregnant
Women**
Suckling
Women**
Menstruating
Women**
*‫فديةَطعامَمسكين‬
* *‫قضاءَماَعليهَيومَمقابلَيومَقبلَمجئَرمضانَالتالي‬
Minors Traveler**
Mentally
Impaired
‫ن‬َ‫م‬َ‫ف‬ََ‫ان‬َ‫ك‬‫م‬ُ‫ك‬‫ن‬ِ‫م‬‫ا‬ً‫ض‬‫ي‬ ِ‫ر‬َّ‫م‬َْ‫و‬َ‫أ‬َ‫ى‬َ‫ل‬َ‫ع‬ََ‫ف‬َ‫س‬َ‫ر‬َ‫ة‬َّ‫د‬ِ‫ع‬َ‫ف‬َْ‫ن‬ِ‫م‬َ‫َّام‬‫ي‬َ‫أ‬ََ‫خ‬ُ‫أ‬ََ‫ر‬َ‫ى‬َ‫ل‬َ‫ع‬ َ‫و‬
ََ‫ين‬ِ‫ذ‬َّ‫ال‬َُ‫ه‬َ‫ن‬‫و‬ُ‫ق‬‫ي‬ِ‫ط‬ُ‫ي‬َ‫ة‬َ‫ي‬ْ‫د‬ِ‫ف‬َُ‫م‬‫ا‬َ‫ع‬َ‫ط‬َِ‫ك‬ْ‫س‬ِ‫م‬َ‫ين‬َۖ

• In spite of fasting in Ramadan is practised by
many many Muslims worldwide, there is yet
no clear scientific consensus on its effects
many health issue
• Even in diabetes all are Expert opinion rather
than strong evidence based practice.

• Mark Ramadan on your office calendar, and
prepare to be the one that brings up the topic
for discussion. Patients are unlikely to initiate
the discussion.
• Inquire about past experiences during
Ramadan fasts, and plans for the upcoming
Ramadan.

• Consider a switch to slow-release or once-
daily medications for the month of Ramadan.
• Recommend dosing schedules coincident with
pre-dawn (Suhoor) and sunset (Iftar) meals.

•‫ا‬َ‫م‬َ‫و‬َ‫ل‬َ‫ع‬َ‫ج‬ْ‫م‬ُ‫ك‬ْ‫ي‬َ‫ل‬َ‫ع‬‫ي‬ِ‫ف‬ِ‫ين‬ِ‫الد‬ْ‫ن‬ِ‫م‬‫ج‬َ‫ر‬َ‫ح‬
‫اآلية‬ ‫الحج‬ ‫سورة‬78
‫هللا‬ ‫عبد‬ ‫بن‬ ‫علي‬ ‫فقال‬:‫الحرج‬:‫الضيق‬,‫مخ‬ ‫الكفارات‬ ‫هللا‬ ‫فجعل‬‫من‬ ‫رجا‬
‫ذلك‬,‫ذلك‬ ‫يقول‬ ‫عباس‬ ‫ابن‬ ‫سمعت‬.

•‫عن‬‫أبي‬‫هريرة‬‫رضي‬‫هللا‬‫عنه‬،‫قال‬:‫سمعت‬‫رسول‬‫هللا‬‫صلى‬‫هللا‬
‫عليه‬‫وسلم‬‫يقول‬:(‫ما‬‫نهيتكم‬‫عنه‬‫فاجتنبوه‬،‫وما‬‫أمرتكم‬‫به‬‫ف‬‫أتوا‬
‫منه‬‫ما‬‫استطعتم‬‫؛‬‫فإنما‬‫أهلك‬‫الذين‬‫من‬‫قبلكم‬‫كثرة‬‫مسائلهم‬،
‫واختالفهم‬‫على‬‫أنبيائهم‬)
‫رواه‬‫البخاري‬‫ومسلم‬.

‫حدثنا‬‫قتيبة‬‫بن‬‫سعيد‬،‫حدثنا‬‫عبد‬‫العزيز‬‫بن‬‫محمد‬،‫عن‬‫عمارة‬‫ب‬‫ن‬
‫غزية‬،‫عن‬‫نافع‬،‫عن‬‫ابن‬‫عمر‬‫قال‬:‫قال‬‫رسول‬‫هللا‬‫صلى‬‫هللا‬‫عل‬‫يه‬
‫وسلم‬:”‫إن‬‫هللا‬‫يحب‬‫أن‬‫تؤتى‬‫رخصه‬،‫كما‬‫يكره‬‫أن‬‫تؤتى‬
‫معصيته‬“
‫هللا‬ ‫رحمه‬ ‫االلباني‬ ‫صححه‬
‫مسند‬‫أحمد‬‫بن‬‫حنبل‬-‫ومن‬‫مسند‬‫بني‬‫هاشم‬‫مسند‬‫عبد‬‫هللا‬‫بن‬‫عمر‬‫رضي‬‫هللا‬‫عنهما‬-‫حديث‬:5703

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