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.
What can you do for your fasting Muslim patients during Ramadan?
- Adjust timing of medication;
- Consider switching to an extended release formulation or to injectable forms of medications;
- Counsel patients about the risk of dehydration, nutritional requirements and electrolyte abnormalities, and advise them to hydrate and consume well-balanced pre-dawn and evening meals, with an emphasis on complex carbohydrates and fiber-rich foods to start and end the fast;
- Encourage keeping up to date with vaccination schedule; and
- Consider trial fasts (e.g., one month before Ramadan).
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.
Islam is the second-most widely practiced religion in the world (after Christianity) and one of three Abrahamic faiths, alongside Judaism and Christianity.1 Its inception was in the year 1432 AD in the city of Makkah (Mecca).
Currently, more than 1.8 billion individuals are Muslim. Islam, at its core, is promotes the religion of Abraham, who is also considered a prophet in both Christianity and Judaism. Islam confirms the message presented to prior prophets of God, such as Noah, Moses, David, Solomon and others mentioned in the Old Testament, the New Testament and the Torah.
The five pillars of Islamic faith are:
- Declaration of faith, which entails believing in the oneness of God (Allah), with Muhammad (peace be upon him) as his prophet and final messenger;
- Performing five daily prayers;
- Giving alms (2.5% of every earning of individual wealth once it reaches a certain amount and is maintained for one lunar year);
- Observing the fast during the month of Ramadan; and
- Traveling to perform the Hajj (pilgrimage) once in a lifetime, if able.
Ramadan is the ninth month of the Islamic calendar, which is based on the lunar, rather than the solar or Gregorian, calendar. Due to this, the dates for Ramadan change by 10–12 days every year, allowing it to fall in every season over an approximately 33-year cycle. It is during this month that Muslims believe the Muslim holy scripture, the Quran, was initially revealed by Allah (the Arabic word for God, similar to Elah in Aramaic) through the archangel Gabriel to the Prophet Muhammad, peace be upon him (pbuh). According to tradition, the Quran was revealed over approximately 23 years and compiled into script as it was being revealed.
Muslims observe the month as a period of introspection, prayer and self-improvement. It is a month of communal prayer (salāt) in the mosque (a place of worship) and reading of the Quran. Muslims believe God forgives the past sins of those who observe the holy month with fasting, prayer and faithful intention.2 Further, able-bodied Muslims are obligated to observe a fast from dawn to dusk. Fasting is a form of self-restraint, not only from food and drink but also from sexual activity and from all behaviors considered immoral or harmful, such as false words, bad deeds, smoking and poor intentions.
Muslims can observe Ramadan through charity, such as feeding a less-privileged person, in lieu of fasting if one is unable to fast due to health-related reasons. The overall goal is to improve oneself to a higher degree and maintain this self-improvement throughout the year until the next Ramadan arrives.
Fasting is a tradition practiced by many Abrahamic faiths. Traditionally, times for fasting include Lent, Yom Kippur, Tisha B’av, 17th of Tammuz and 10th of Tevet.
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 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.
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.
- Vaughan D. What is the most widely practiced religion in the world? Encyclopedia Britannica. 2020 May 19.
- Ramadan. Encyclopedia Britannica. https://www.britannica.com/topic/Ramadan.
- Song DK, Kim YW. Beneficial effects of intermittent fasting: A narrative review. J Yeungnam Med Sci. 2023 Jan;40(1):4–11.
- Hwangbo DS, Lee HY, Abozaid LS, et al. Mechanisms of lifespan regulation by calorie restriction and intermittent fasting in model organisms. Nutrients. 2020 Apr 24;12(4):1194.
- Zarrinpar A, Chaix A, Yooseph S, et al. Diet and feeding pattern affect the diurnal dynamics of the gut microbiome. Cell Metab. 2014 Dec 2;20(6):1006–1017.
- Chapnik N, Genzer Y, Froy O. Relationship between FGF21 and UCP1 levels under time-restricted feeding and high-fat diet. J Nutr Biochem. 2017 Feb;40:116–121.
- Di Francesco A, Di Germanio C, Bernier M, et al. A time to fast. Science. 2018 Nov 16;362(6416):770–775.
- Mattson MP, Moehl K, Ghena N, et al. Intermittent metabolic switching, neuroplasticity and brain health. Nat Rev Neurosci. 2018;19:63–80.
- Schübel R, Nattenmüller J, Sookthai D, et al. Effects of intermittent and continuous calorie restriction on body weight and metabolism over 50 wk: A randomized controlled trial. Am J Clin Nutr. 2018;108:933–945.
- Sabiq S. Fiqh-us-Sunnah Volume 3. https://islamicstudies.info/subjects/fiqh/fiqh_us_sunnah/fus3_50.html.
- Wang X, Yang Q, Liao Q, et al. Effects of intermittent fasting diets on plasma concentrations of inflammatory biomarkers: A systematic review and meta-analysis of randomized controlled trials. Nutrition. 2020 Nov-Dec:79–80:110974.
- Abolaban H, Ahmad AM. Muslim patients in Ramadan: A review for primary care physicians. Avicenna J Med. 2017 Jul-Sep;7(3):81–87.
- Khan G. See how Muslims celebrate Eid al-Fitr around the world. 2023 Apr 17.