Ramadan is actually the name of a month in the Muslim calendar. Ramadan is a basic principal of Islam that involves fasting from dawn to sunset for one lunar month. During Ramadan, adult and healthy Muslims are required to refrain from taking any food, beverages, or oral drugs as well as from sexual intercourse between dawn and sunset in an effort to achieve better self control. The length of fasting time varies with the geographical position of the country and the season in which the month of Ramadan falls. Therefore, the length of the fast may vary from 10 to 19 hours a day.
During this month, usually two meals are eaten per day. The first meal, called iftar, might be taken immediately after sunset. And before dawn, people wake up to have a meal called sahur to prepare themselves for fasting.1 So, lifestyle and circadian rhythms change during Ramadan.
According to the Islamic rules and Qur’an texts, young children who have not reached the age of puberty, menstruating women, or women who are still breast-feeding, the chronically ill, elderly people, the insane, and the travelers are exempt from fasting during Ramadan.2 Every year, millions of Muslims throughout the world fast from sunrise until sunset daily during the month of Ramadan, that is, they experience repeated cycles of fasting-refeeding. Naturally, this causes significant changes in the normal feeding, sleeping, and behavioral patterns of the people practicing the fast. Modification of meal frequency and eating patterns during Ramadan may affect different aspects of human health.
Most of the current major diseases such as heart disease, stroke, cancer, and osteoporosis are progressive, largely irreversible, and primarily dependent on diet and lifestyle factors, and are relatively difficult to address effectively with drug treatment.3
The Ramadan may have several effects on basic homeostatic functions. In people who are well, normal homoeostatic mechanisms seem to cope: urinary volume, electrolytes, pH, and nitrogen excretion remain within physiological limits. Some studies have reported substantial weight loss and increased plasma concentrations of urea and uric acid consistent with catabolism of body mass, but these findings have note been confirmed.4 Some of the variations may be attributable to local traditions and food quality. Observance of this religious tenet by Muslims displaces energy intake and hydration to the hours of darkness and partly reverses the normal circadian pattern of eating and drinking. The long duration of diurnal fasting means that hunger, energy levels, and subjective fatigue are increased above those habitually experienced at other times of the year. In addition to the avoidance of solid food, fluid intake is also eschewed during daylight hours. A gradual dehydration therefore occurs until body water status can be restored after darkness. Given that severe hypohydration can lead to impairments in exercise performance, the lack of fluid intake compounds the effects of energy losses during the day. There are likely to be knock-on consequences for renal function as well as endocrine function during daytime, particularly secretion of antidiuretic hormone and aldosterone.5
Compliance with drug therapies seems to fall during Ramadan, leaving these patients vulnerable to their underlying medical conditions. Researchers in many fields of medicine have investigated the feasibility of specifically modifying the time and type of drug treatment for fasting patients out of respect for their religious beliefs. Oncologists who practice in Islamic countries and treat patients with cancers, however, are faced with a difficult problem: Some of their patients are determined to abide by their religious custom of fasting during Ramadan despite the existence of limitations such as impaired performance status or ongoing therapy.
Islam forbids fasting if this would be harmful to the individual. A person who deliberately puts his health at risk by fasting against the advice of his physician contradicts this basic principle of Islam. Therefore, appropriate advice from a doctor during Ramadan may encourage patients to continue their treatments and prevent irreversible damage as a result of disease.
Obviously, a persuasive, firm approach by physicians to convince their patients to refrain from fasting might work in some patients; however, it might cause other patients to distrust their physicians, which in turn might lead to a breakdown in communication or a loss of the patient to follow-up. Nevertheless, we try our best to persuade patients with curable diseases, such as lymphoma, to continue to receive chemotherapy even during the time of Ramadan.
Physicians should be aware of Ramadan and determine fasting practices among their Muslim patients to detect potential complications arising from this practice. In the mean time, these patients should be preferably treated by a team made up of the medical oncologist, the psychiatrist, and perhaps a local religious authority figure. Mosque imams (priests) can play a major role in advising patients and should be educated on this subject.
AUTHOR'S DISCLOSURES OF POTENTIAL CONFLICTS OF INTEREST
The author(s) indicated no potential conflicts of interest.
NOTES
published online ahead of print at www.jco.org on October 20, 2008
REFERENCES
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circadian time structure in humans: A study on plasma gastrin, insulin, glucose,
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