What Every Clinician Should Know about Ramadan & Intermittent Fasting

Intermittent fasting—defined as alternating between cycles of eating and going without food over a given period of time—has become popular with individuals seeking to lose weight or balance their lifestyle in recent years. During Ramadan (a period based on the Gregorian calendar that changes from year to year), able-bodied Muslims are obligated to observe a fast from dawn to dusk, refraining from food and drink. This year, Ramadan begins at sundown on Sunday, March 10, and ends on April 8 (predicted based on the lunar cycle). Rheumatologists and rheumatology professionals need to be aware of how such fasting could affect their patients.

The Benefits of Fasting

Within medicine and through scientific research, the benefits of fasting have been established, particularly in diabetes and cardiovascular literature. Metabolic dysregulation, such as insulin resistance, hypertension, dyslipidemia and atherosclerosis, has been improved by establishing caloric restriction without malnutrition.

Caloric restriction reduces body weight and increases life expectancy in obese individuals. It has been shown to improve insulin sensitivity, cardiovascular risk factors and mitochondrial dysfunction. Long-term, daily caloric restriction is difficult to adhere to, which is where intermittent fasting has excelled. It has come into favor as an alternative for caloric restriction to achieve the goals of reducing the adverse effects of obesity, insulin resistance and cardiovascular disease by playing a role in reducing systemic inflammation.³

Weight reduction is the main benefit of intermittent fasting. Intermittent fasting has been shown to reduce fasting insulin plasma levels and the overall body inflammatory status by regulating various cytokines that promote inflammatory pathways, which are well established in rheumatic and autoinflammatory conditions. Cytokines, such as the mechanistic target of rapamycin (mTOR), AMP‐activated protein kinase (AMPK) and autophagy, have been shown to be regulated with implementation of intermittent fasting.⁴

During the fed state, signaling pathways for nutrient sensing and cellular growth (e.g., mTOR) are activated. Stress-responsive signaling pathways (e.g., FOXO and AMPK) are activated by fasting, resulting in the protection from cell damage and inhibition of cell proliferation.

An additional mechanism of intermittent fasting is the metabolic switch between fed and fasting states. Fasting, especially repetitive fasting, induces organisms to shift their metabolic phase, which improves metabolic conditions and extends health expectancy.

It has also been reported that fasting optimizes cellular use of fuel sources, favoring ketone bodies and fatty acids over glucose, which ameliorates the blunting of metabolic flexibility observed in obesity and type 2 diabetes mellitus and improves mitochondrial function.

Further, fasting activates autophagy and defense mechanisms against oxidative and metabolic stress and suppresses inflammation.^5-8 These effects of intermittent fasting are similar to those of aerobic exercise.⁹

Macrophages infiltrate hypertrophied adipose tissue and produce proinflammatory cytokines, including interleukin (IL) 6 and tumor necrosis factor-alpha (TNF-α), which induce insulin resistance and atherosclerosis and are linked to the systemic inflammation that we are familiar with in rheumatic and autoimmune conditions. Systemic inflammation is linked to the pathogenesis of type 2 diabetes mellitus, cardiovascular diseases, cancers and rheumatic autoimmune conditions. Thus, systemic inflammatory markers may predict the development of these metabolic disorders.³

Body weight reduction decreases adipose tissue macrophages, reduces proinflammatory cytokines, and improves insulin resistance and systemic inflammatory states. Several clinical trials have shown that intermittent fasting intervention improves inflammatory status in obese subjects, demonstrating a reduction in C-reactive protein, and mixed results regarding reduction in plasma levels of IL-6, TNF-α and interferon-γ, markers that rheumatologists have been targeting with both biologic disease-modifying anti-rheumatic drugs (DMARDs) and conventional DMARDs to treat autoimmune conditions.¹¹

Your Muslim Patients

Ramadan is a month of introspection, prayer and self-improvement, and it is safe to assume the majority of Muslim patients will be observing fasting in some capacity this year. Some may observe fasting the entire month, as recommended. Others may miss fast days for various reasons and make them up at a later time in the year.¹⁰

Pregnant (or nursing) women, menstruating women, post-partum women (who are still bleeding), children, the elderly, travelers on a long journey, those with chronic diseases (e.g., diabetes, autoimmune disease) and the mentally ill are exempt from the fasting requirement.

Ramadan is the largest Muslim celebration of the year. As a result, there is a strong desire to participate in all activities even when exceptions can be made due to chronic disease. Thus, many individuals choose to fast and do not necessarily disclose this information to their healthcare professionals unless they are specifically asked.

Caring for patients during this time will require their healthcare team, including rheumatology professionals and pharmacists, to play an active role.

Individuals who take medications for chronic conditions may need to adjust the timing of their medications to either before sunrise or after sunset. For medications that need to be taken multiple times a day, you may need to switch your patient to a long-acting formula or change the dose to daily or twice daily. For more short-term medications, such as non-steroidal anti-inflammatory drugs (NSAIDs), acetaminophen and pain medication (codeine, tramadol), once-daily dosing is preferred. Non-oral medications (i.e., injectable, topical or intravenous medication) are usually allowed during a fast.

Many of the medications used in rheumatology can potentially be toxic to the renal system and gastrointestinal tract unless proper measures are taken to help prevent stress on these systems. Encouraging patients to hydrate as much as possible during the hours between their fasts is essential to help curb some of the adverse effects that may occur due to medication use.

Additionally, adjusting the dose of medications to fall before sunrise or after sunset and taking the medication after or with food may reduce effects on the gastrointestinal tract.

It is commonly believed that receiving vaccinations (subcutaneous) is permitted during the fast given that the majority of vaccines are not oral.¹²

Clinicians

Clinicians and individuals on the healthcare team may also be Muslim and are likely to be fasting during this month as well. The fast should not affect their ability to take care of patients, and most healthcare individuals’ understanding of physiology allows them to recognize the limits to patient care if there is any hesitancy.

Fasting should not affect the ability of a Muslim healthcare team member to help care for the patient and should not affect their decision-making capacity. However, some clinicians and healthcare professionals may adjust their schedule to optimize the timing of work during Ramadan to allow for prayer and contemplation. Some individuals may choose to start work earlier (such as when making hospital rounds), and others may choose to limit the total number of patients seen in their clinic during the day by working through the lunch hour and ending clinic earlier than their usual time if their schedule and work setting allow.

In Sum

Ramadan is not only a month of fasting, prayer, introspection and worship. It is also a month of self-improvement and purification. The end of Ramadan marks a religious holiday, Eid ul-Fitr, Arabic for “festival of breaking fast.” It is celebrated over three days at the end of Ramadan with prayer, feasts, parades, gifts and charitable giving.¹³

The majority of Muslims will participate in Ramadan in some capacity, including fasting. Healthcare delivery can continue to be effective during Ramadan even if slight modifications need to be made to medication regimens and schedules.

To optimize care and promote the safety and trust of our patients, we must demonstrate cultural competence and knowledge about the basics of Ramadan. We must aim to familiarize ourselves with fasting, treatments and procedures that invalidate a fast and the effects fasting may have on medication use and disease state.

Although clear guidelines are not always available to manage rheumatic conditions, many resources, such as Muslim clinicians, Islamic-based healthcare organizations and scholars of Islamic faith, can assist with establishing individualized healthcare to bridge the gap in knowledge and improve overall outcomes.

Mohammad A. Ursani, MD, FACP, RhMSUS, is a private practice rheumatologist in The Woodlands, Texas. He also serves as a volunteer for the ACR and acts as the chair for the ACR’s Committee on Marketing & Communications. Additionally he serves as a delegate for the Texas Medical Association.

Iman Qaiser, MD, completed a rheumatology fellowship at Louisiana State University (LSU) Shreveport in 2023. She is currently working as the only rheumatologist for the Choctaw Nation of Oklahoma in Durant. She is also a member of the ACR Workforce Solutions Committee.

Mamdouh Mahmoud, PhD, is the founder and CEO of Roots and Sprouts, an educational and religious consulting firm. He is the imam and resident scholar of the Islamic Society of Greater Houston, and holds a doctorate in Islamic studies.

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