Fasting Of Ramadan And Its Concessions

By Muhammed Sirajuddin (M.D., F.A.C.G., F.A.C.P)

Each year as Ramadan approaches, millions of Muslims brace themselves, physically, mentally, and spiritually, to fulfill the perennial obligation of fasting and bask in the saintly ambience fasting creates in and around the observers of this elemental ritual of Islam. But among those eager millions there are many whose desire to fast be eclipsed by a myriad of health problems that render them physically unfit to fast even though they may be spiritually geared up.

However, Allah, out of His mercy, has good news for this category of legally responsible Muslims. In the same verse in which Allah pronounced the obligation of fasting, He exempted from this duty, either permanently or temporarily, those who are hindered from it by forbidding physical ailments, old age, travel, etc. Allah Says:

“The month of Ramadan [is that] in which was revealed the Qur’an, a guidance for the people and clear proofs of guidance and criterion. So whoever sights [the new moon of] the month, let him fast it; and whoever is ill or on a journey – then an equal number of other days. Allah intends for you ease and does not intend for you hardship and [wants] for you to complete the period and to glorify Allah for that [to] which He has guided you; and perhaps you will be grateful.”[Al-Baqarah, 2: 185]

In the following, we will provide a general medical overview of the different types of diseases and health conditions fasting persons or those intending to fast might be afflicted with, and to what extent do these diseases and conditions affect their ability to fast, and what are the recommendations medical doctors offer in this regard.

Deferred Fasting And Atonement.

1. The traveler.

2. The ailing.

3. Those for which it may be difficult rather than easy.

4. Menstruating female: Menstrual bleeding cause’s physical impurity [Al-Baqarah, 2:222]. Some might even feel physically weak and emotionally depressed. Some degree of pain and discomfort is very common. During her period, a woman should not fast; she should start fasting only when she is clean. She is required to make up the days she missed at a later date.

5. Pregnancy.

6. Breast feeding mothers: Fasting may lead to reduced milk production by the mother and if the baby is dependent solely on its mother’s milk, it may critically affect the baby’s health. If the circumstances call for, mother should defer fasting for later days or make alternative arrangements, e.g., atonement.

7. Disability due to old age, e.g., simple physical weakness which can be complicated by calorie deprivation or dehydration. Since old age is irreversible, regular atonement will be necessary.

8. Chronic irreversible pathological conditions e.g., old age dementia or Alzheimer’s disease may need regular atonement.

9. Psychological disorders: depending on the reversibility, persons suffering from these disorders may need temporary or permanent atonement.

10. Any chronic illness where there are less chances of recovery and fasting may further complicate the situation e.g., some form of Diabetes Mellitus or any other condition that requires frequent medications and monitoring of patient’s condition, atonement will be the alternative means.

It is noteworthy that there is no permanent exemption from fasting.

Pregnancy and Ramadan fasting.

To understand the effect of fasting on pregnancy, one must have at least basic knowledge about the global changes that happen to a pregnant woman. A detailed account, however, is available from any textbook of obstetrics. For the purpose of this article, only a brief reference has been made to the chapter 13, Maternal Adaptation to Pregnancy, p. 223 and chapter 14, Prenatal Care, p. 235, of Thomas R. Moore’s book Gynecology & Obstetrics.

Maternal adaptation to pregnancy:

Although pregnancy is considered to be a physiological condition to the patient, the physical and psychological changes that occur in pregnancy may be confusing and may be interpreted as pathological.

Near the end of nine months of pregnancy, a woman may find that she has gained an average of 22 to 26 lbs. in weight, that she experiences swelling of her face, hands and ankles, and that she is short of breath on moderate exertion. She may experience urinary incontinence, constipation, and hemorrhoids, as well as difficulty in standing for prolonged periods because of lower-back pain and sciatica. Sleep may be interrupted several times a night because of uterine discomfort and the need to empty her bladder. All these changes arise from the orderly bodily changes dictated by the rising levels of hormones elaborated by the placenta and by the growth of the fetus.

Recommended calorie intake in normal pregnancy.

During the normal course of pregnancy, an average of 80,000 kcal is required above the energy requirement of the non-pregnant state. This amounts to an additional 300 kcal/day–– which can be provided by one pint of low fat milk, one peanut butter sandwich, or less desirably one can of soda and 10 French fries (Hytten FE, Leitch I. (1971), Physiology of Human Pregnancy). Current recommendation for total dietary intake in healthy, adult pregnant women is 2000 2700 kcal/day.

Normal pregnancy weight gain.

Average pregnancy weight gain in North America is 33 +/- 12 lbs. Nevertheless, significant variation among individuals is expected because of differences in height, body type and pre-pregnant weight.

Weight gain and prenatal mortality.

In North America maternal weight gain is a minor contributor to pregnancy outcome; therefore, dietary recommendations for pregnant women should be individualized.

Effect of calorie restriction on pregnancy outcome.

Contrary to ordinary belief, even severe calorie restriction has minimal impact on pregnancy outcome. During WW2, calories provided to people in the Netherlands were reduced from 2000 kcal to 70 kcal/ day. This resulted in no impact on first and second trimesters, and only a small reduction in birth weight of babies born to mothers in the third trimester from 3370 to 3150 g (a drop of 220 g, or 6%). However, no cases of stillbirth, prematurity, or lactation were recorded.

Pregnancy nutritional supplementation:

•Calories: 2000-2700 kcal/day

•Protein: 30g additional

•Iron : 60mg/day

•Folate : 400 800 micg/ day

•Calcium : 400 mg additional

Observations:

1. There is tremendous amount of physical and psychological adaptations that the body need to make to accommodate pregnancy. The pregnant mother constantly lives in fear not about herself but about the health and future of the unborn baby. Out of love for some one that she has not yet seen, she is ready to sacrifice anything and everything for the wellbeing of the unborn.

2. Recommended amount of total calories per day is 2000-2700 kcal.

3. Average daily calorie requirement of growing fetus is 300 kcal. This amount, however, will vary according to the gestational age of the fetus. Requirement is much more during second and third trimesters but does not call for a significant increase in the total calorie intake of the mother.

4. Except in cases of extreme malnutrition and obesity, marked alteration in maternal dietary habits is not likely to improve pregnancy outcome. 

Fasting In [During] Pregnancy.

In pregnancy, there is always a consideration of “two in one”- the mother and the fetus. In the early part of pregnancy, the need of the fetus is insignificant; however, the mother usually goes through morning sickness and sometimes emotional changes. Depending on the degree of changes one may need medical attention and/or psychological counseling. As the pregnancy progresses, the mother enters into different phases of physical changes and the needs of the fetus also continue to grow. The average daily calorie requirement of a growing fetus is 300 kcal which can very easily be provided from mother’s calories. Therefore, as long as the mother is taking an adequate amount of calories, that should suffice the need of the fetus.

In the state of fasting, in case of normal pregnancy, the requirement of total fluid and calorie intake is no different than that of the pre-pregnant status. However, what are more important are the tremendous physical and emotional adaptations that are necessary to ensure a normal outcome of pregnancy. Therefore, any additional factor that may influence this delicate balance should be avoided. Since the degree of physical and emotional changes and the degree of adjustability to these changes will vary from one person to another and according to their experience, recommendation regarding fasting in [during] pregnancy must be individualized. “Not to fast during pregnancy” is a blanket concession that conforms to what Allah Says:

“. . . Allah intends for you ease and does not intend for you hardship …” [Al-Baqarah, 2: 185]

Using this concession is advisable when necessary, keeping in mind that this is only a deferment, not an exemption.

Diabetes Mellitus And Fasting.

Diabetes Mellitus is a common problem. It is a serious, chronic and irreversible condition; however, it is controllable with prudent management schedule.

Allah Tells us that fasting is a means of attaining piety. Because there are so many spiritual benefits in fasting. Many Muslims find it hard to let such opportunity pass by without deriving any benefit from it. Therefore, they will resort to fasting despite their knowing that they could defer it or make arrangement for atonement.

From a medical point of view, fasting has a soothing effect on the mind, and it helps one achieve inner peace and self control. It also helps in controlling blood sugar and blood pressure by controlling eating, excitement and anger.

On the other hand, besides suffering from clinical symptoms of polyuria, polydypsia and other complications, a diabetic patient also suffers from psychological symptoms arising directly from changing blood and CSF osmolality, constant demand of discipline and compliance, fear of long term complications and threat of hypoglycemic attacks and possibility of dehydration and coma. (“Diabetes Mellitus and Fasting,” Shahid Athar, M.D., journal of IMANA, March 2006)

Because of the spiritual and medical benefits on one hand, and adverse consequences (in some cases) of fasting, on the other hand (in some cases), any recommendation for or against fasting should be made only after a global evaluation of a patient. In such evaluation an answer to the following questions may help in arriving at a reasonable recommendation:

1. Is there a group of diabetics who can be safely guided to fast?

2. Should every diabetic who wants to fast be allowed to do so?

3. Is there a group of diabetics who should be advised against fasting?

4. Can some diabetics benefit from fasting?

5. How dependable is the patient?

6. Are there any associated compounding medical/psychological conditions?

The above questions can be briefly answered as follows:

1. Fasting encouraged––Patients with uncomplicated metabolic syndrome including obesity, type 2 diabetes mellitus, hypertension, and/or hyperlipidemia. Fasting in this group of patients will have therapeutic effect.

2. Relative indications––Patients with the following criteria can relatively safely be guided to achieve Ramadhan fasting [fast Ramadhan]:

a) Age above 20, ideal or above ideal body weight, stable diabetes on oral hypoglycemic.

b) Free of any complication or any compounding medical problem (infection, or renal, cardiac, pulmonary, vascular and/or neurological conditions).

c)  Should have the following biochemical parameters: Fasting blood sugar between 110-120 mg/dl, 2-hr post-prandial blood sugar not exceeding 160 mg/dl, and HbA 1c less than 7%.

3. Relative contraindications––Diabetic females who are pregnant and nursing mothers.

4. Patients who should not fast:

a) Type 1 and unstable diabetics

b) Presence of infection and other life threatening systemic diseases

c) HbA 1c over 12% or history of frequent hypoglycemia.

Educational program for diabetics during Ramadhan:

Patients should be able to:

1. Recognize the symptoms of hyperglycemia, hypoglycemia and dehydration and the importance of breaking fast as soon as any complication occurs.

2. Monitor blood sugar, check urine sugar and urine acetone, daily weight, calorie-controlled diabetic diet and carry on normal physical activities.

3. Monitor vital signs; recognize signs of infection and any alteration in mental state.

4. Follow dietary advice, drug regime adjustment and seek help if a problem occurs.

Dietary guidelines and adjustment of medication.

All patients with diabetes who are willing to fast should be under strict supervision of [by] their physician. Patients should start preparing themselves 2 to 3 months before the onset of Ramadhan and strictly follow the guidelines given by the physician. These may include a physical examination, blood and urine tests, and a CMP among others. Special attention must be paid to any change in the schedule of oral medications and insulin injection.

In conclusion, concessions are mercy from Allah. One should take advantage of the concessions when the reasons are legitimate; however, it should not be misused out of insincerity, a state that is capable of developing into disobedience.

The scholars and the physicians can set parameters for different categories, but the actual limits should be set by the sincerity of the individual. For some of us, we should know that where there is a will there is a way, as Allah Says:

“. . . And whoever fears Allah – He will make for him a way out.” [At-Talaq, 65:2]

 [Via Islam Web]

About Md Radzi Ahmad
A retired Malaysian civil servant. Served the Malaysian government for thirty-one years. Posted to London, Rangoon, Johannesburg, Pretoria and Bangkok. Born in Kampong Hutan Kandeh, Alor Star, Kedah. Educated at Sultan Abdul Hamid College, Alor Star and University of Malaya, Kuala Lumpur. Currently resides in Subang Jaya, Selangor Darul Ehsan,Malaysia.Blessed with three children, a son, two daughters, daughter in law and two grandaughters.

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