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Features: May 2018

Ramadan 2018

Upcoming Fasting Holiday: Consider Medical & Scheduling Implications for Some Patients

It is anticipated that Ramadan will start Wednesday, May 16th and last for 30 days until Thursday, June 14th. Note that in the Muslim calendar, a holiday begins on the sunset of the previous day, so observing Muslims will celebrate Ramadan beginning on the sunset of Tuesday, May 15th. Many Muslims, including many in the local community, will follow dates established by the sighting of the moon in Muslim countries such as Saudi Arabia. Beginning and ending dates may therefore vary. Ramadan is the ninth month of the year in the Islamic calendar.

Clinical Considerations: During Ramadan, Muslims will abstain from food and drink from dawn to sunset. In northern locations like Seattle, the days this year will be long, around 15-16 hours. There can be medical and scheduling implications of fasting for some patients. For those who fast, the diurnal pattern of caloric intake is obviously reversed and diabetic medication schedules will have to be adjusted to accommodate this significant change. Sometime in the month prior to Ramadan a discussion between provider and patient should take place to plan medication adjustments. Consider scheduling visits with primary care provider and with a dietitian to establish a Ramadan meal plan (and pharmacist if needed for medication consultation). Consider asking the patient to practice with their new regimen prior to Ramadan and have a plan if additional adjustments are needed.

Blood draws, anticoagulation, breastfeeding regimens, TID regimens, surgeries and other procedures may also merit special consideration during Ramadan. Senior doctors might consider bringing this to the attention of new interns who may not be in the habit of thinking about Ramadan when prescribing medication, scheduling procedures, and arranging follow-up on discharge from the hospital.

Health care providers should be vigilant and ask their patients whether they intend to observe regular or modified fasting. Engage in a full discussion of the degree of the individual’s risk from fasting with the patient who intends to fast. For patients who prefer to fast, individualization of care and frequent monitoring is highly recommended. Patients often have experimented and developed their own regimen. Exploring this with the patient helps build a partnership between patient and provider, capitalizing on the knowledge of both parties.

Patients’ decisions to fast may need to vary year by year, and their participation in the fast may need to become modified as they become more fragile and unable to do the entire fast without risk of dehydration, hypoglycemia, or exacerbation of illnesses requiring daily monitoring or medications. Advise patients with diabetes to monitor BG more frequently during fasting periods. Take into account how long the fast will last. Incorporate the patient’s experiences with control of chronic disease when fasting in previous years into current treatment recommendations.

When in the judgment of a provider, a patient’s health status is considered fragile, the provider can remind the patient about exemptions. It is important to remember that this is a total fast during the long daylight hours of mid-May to mid-June. This means people are NPO for 15 or more hours. For example, if a patient has renal insufficiency, is hypotensive, or is dysautonomic and being mildly dehydrated may compromise their fluid balance or other underlying state, a conversation about fluids and food consumption and the wisdom of an exemption is in order.

Health care settings might consider providing support for patients to maintain their religious practices. Islamic patients are more likely to keep their clinic appointment if they know a room is available to maintain their prayer times during their month-long Ramadan observance. Eid-al-Fitr is a day of celebration marking the end of Ramadan, and in order to avoid no-shows, clinics may want to take steps to avoid scheduling appointments on this day. Throughout Ramadan, Muslims gather as family and community in the evenings to break their fast. Inpatients may receive an increasing number of visitors during this month.

Fasting Exemptions and Extra Fasting:

Based on the Quran, those who are sick, on a journey, or women who are menstruating, pregnant or nursing are permitted to break the fast and make up an equal number of days later in the year: [2:185]. Persons who are sick, elderly or chronically ill, for whom fasting is unreasonably strenuous, are required to feed at least one poor person for every day in Ramadan for which he or she has missed fasting, and are then not expected to make up the fast later. There are provisions made for paying back missed fasting days as practical aspect of the faith. It can be useful for providers to remind patients of this option; it sometimes allows one to negotiate important compromises. Muslim patients may still choose to fast because, to most, Ramadan is believed to be the most blessed and spiritually-beneficial month of the Islamic year.

Some people will choose to fast an additional 6 days after Ramadan, beginning the day after Eid-al-Fitr (celebration marking the end of Ramadan). This extra fasting combined with the 30 days of Ramadan fasting is accepted by some Islamic scholars as the equivalent of fasting for one entire year. This type of fasting is called sunnah fasting.

Read more on EthnoMed: including information about management of diabetes and breastfeeding during Ramadan.

See also Avicenna J Med article: Muslim patients in Ramadan: A review for primary care physicians


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