Fasting, and Associated Problems

This article shall give general guidelines regarding Ramadan fast in those who have acid peptic diseases and other gastrointestinal and liver disorders.
Fasting, and Associated Problems
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Fasting during the month of Ramadan is one of the five pillars of Islam and one of the essential commitments to faith for every Muslim.

Every year prior to Ramadan, many patients with acid peptic diseases and related disorders would like to know whether they can fast, and if so what precautions they need to take during fast about their medication and diet.

 This article shall give general guidelines regarding Ramadan fast in those who have acid peptic diseases and other gastrointestinal and liver disorders.

Gastro-esophageal reflux disease (GERD): GERD is a common disorder and affect 10 to 15 percent of general population all over the world. Such patients complain of acidity, acid regurgitation, heart burn, and may develop ulcers and strictures in the food pipe. Reflux may cause Barret's esophagitis and rarely lead to cancer. Some patients with GERD may develop acid reflux in to throat, larynx and lung and cause chronic cough, hoarseness and even excerebration of asthma.

Many patients with GERD may have associated hiatus hernia. GERD has a broad spectrum of manifestations and decision on Ramadan fast is dependent upon the severity of GERD manifestations and nature of underlying disease. Patients with erosive esophageal disease on active medication should be advised not to fast. Ramadan with long hours of fasting increase serum gastrin and acid which may worsen symptoms and impede healing of erosive disease.

Advice to patients with non-erosive disease or those with healed erosive disease and whose symptoms are controlled with acid reducing pills should be individualized. Many such patients may fast with no problem if symptoms are controlled with acid reducing pill taken once a day. Should symptoms of heartburn, acidity, acid regurgitation worsen during long fasting hours, it is advisable not fast.

Peptic Ulcer: Patients with active peptic ulcer disease cannot fast till ulcer heals and any precipitating cause of ulcer like Helicobacter pylori infection is eradicated or ulcerogenic drugs withdrawn. Patients with silent ulcers or those who have had bleeds from peptic ulcers should not fast as fast may precipitate bleed or cause ulcer perforation.

Some physicians believe that patients with peptic ulcer disease can fast as fast may improve their symptoms and promote ulcer healing. This concept is wrong. There is definite increase in severity of symptoms in patients with peptic ulcer disease during Ramadan fast and many may come up with bleeding and perforation during and soon after Ramadan fast. Studies on volunteers and peptic ulcer patients have shown definite increase in acid and hormone Gastrin (which produces acid from stomach) during fast which persists for a month or more after fast.

Thus patients with active and symptomatic peptic ulcers and those who have had difficult ulcers and/or have bled in the past should not fast on medical grounds. However, patients who have had peptic ulcer in the past and ulcer has healed as proven by upper gastrointestinal endoscopy may fast safely. Some of these patients may need acid reducing pill or antacid tablets or liquid gel if fasting causes dyspepsia. 

Non-Ulcer Dyspepsia: Non-ulcer dyspepsia is a very common disorder and commonest cause of upper abdominal symptoms. These patients present with upper abdominal discomfort, anorexia, bloating, indigestion, and hiccoughs. Such patients have normal upper gastrointestinal endoscopies and normal upper abdominal ultrasounds.

Patients may be infected with Helicobacter pylori infection. Most of these patients take acid reducing pill in the morning and stay fine as long as they continue medication. Fasting in such patients needs to be individualized. If patient can tolerate fast with intake of acid reducing pill at Sahoor, fasting can be allowed. Some patients may get exacerbation of dyspeptic symptoms even after taking the morning pill and should be advised not to fast. A subset of patients with anorexia, bloating and indigestion tolerate fast very well and even feel better with fasting. Ramadan fast in such patients should be encouraged.

Irritable Bowel Syndrome (IBS): IBS is a common disorder in every community including ours.  Such patients present with a wide range of symptoms, including abdominal pain which is relieved by passing wind or defecation, altered bowel habits or constipation and excessive gas.

Many of these patients are milk intolerant and may worsen their symptoms after minor dietary indiscretion. Broadly such patients have been divided in to 2 groups-one with loose motions and other with constipation with passage of ribbon like hard stools.

Few patients may have alternating diarrheal episode followed by constipation. Fasting in patients with IBS should be encouraged and most of such patients improve during fast. However, dietary indiscretion (fried foods or foods with high sugars) at Iftaar may worsen their symptoms and should be avoided. Patients with gas presenting as bloating or indigestion can be allowed to fast safely and symptoms in many such patients regress during fast period.

Liver Diseases: Patients with chronic liver diseases which are stable impose no added risk with fasting. However, chronic liver disease which shows signs of liver failure may worsen with fast and such patients need advice accordingly. Metabolic syndrome presenting as central obesity, dyslipidemia, Diabetes mellitus and non-alcoholic fatty liver disease (NAFLD) has affected our community in an epidemic proportion. Such patients can derive benefit from metabolic consequences (weight reduction, lowering of triglycerides [TG] and low density lipoproteins [LDL] and drop in insulin resistance) of Ramadan fast. Gilbert's syndrome is a benign form of liver disease presenting as recurrent attacks of jaundice (mild elevations of serum bilirubin from1.5 to 6 mg/dl).

Such patients have deficiency of liver enzyme (Glucuronyl transferase) which affects uptake and conjugation of unconjugated bilirubin by the liver cells. Fasting and exercise can further reduce the enzyme levels causing elevation of serum bilirubin and exacerbation of jaundice.

Enzyme levels can be induced by drugs which can relieve jaundice and symptoms in such patients. Advice to such patients regarding Ramadan fast should be individualized. Patients with minimal elevation of bilirubin which does not worsen with fast may fast under supervision. However, if serum bilirubin is elevated (≥2.5 mg/dl) and worsens with fast, patients should be discouraged from fasting and give Fidyah instead.

Diet: Patients with acid peptic diseases and related disorders often ask for dietary advice during Ramadan fast. To remain healthy during Ramadan, normal quantities of food from the major food groups (bread and cereal, milk and dairy product, fish, meat and poultry, bean, vegetable and fruit) should be consumed. Intake of fruits after a meal is strongly suggested.

In actual practice, our diet in Ramadan should not differ very much from our normal diet and should be as simple as possible. The diet should be such that we maintain our normal weight, neither losing nor gaining.

However, if one is over-weight, Ramadan is an ideal time to shed those extra pounds! In view of the long hours of fasting, we should consume the so-called 'complex carbohydrates' or slow digesting foods at Sahoor so that the food lasts longer (about 8 hours) making you less hungry during the day.

These complex carbohydrates have low glycemic index and take long time to convert to glucose in the body and help maintain blood glucose in late afternoon. Such foods include grains and seeds like barley, wheat, oats, millet, semolina, beans, lentils, whole meal flour, and unpolished rice. In contrast, refined carbohydrates or fast-digesting foods last for only 3 to 4 hours and may be better taken at Iftaar to rapidly restore blood glucose levels. Fast-burning foods include foods that contain sugar and white flour.

Dates are an excellent source of sugar, fiber, carbohydrates, potassium and magnesium. Fried foods, very spicy foods and foods containing too much sugar such as sweets can cause health problems and should be limited during Ramadan. They cause indigestion, heartburn, and weight problems. Fasting can often increase gastric acidity levels in the stomach causing a burning feeling, heaviness in the stomach and a sour mouth.

This can be overcome by eating foods rich in fiber such as whole wheat bread, vegetables, humus, beans and fruits. High fiber diets have an excellent effect on our satiety and most suited for Ramadan. In addition these foods trigger muscular action, churning and mixing of food, breaking it into small particles, and thus help reduce the buildup of acid in the stomach.

Acute Illnesses: Apart from above chronic diseases, some acute medical or surgical illnesses may affect gastrointestinal tract and liver and need specific advice regarding fasting.

Acute illnesses affecting gastrointestinal tract and liver  which make people pretty sick such as acute hepatitis, acute cholecystitis, acute GI Bleed, acute gastroenteritis, acute pancreatitis, dysentery, etc. need a strong advice against Ramadan fast for the period of their illness and the recovery period thereafter. Once patient recovers fully from his acute illness and can sustain effects of fasting he can be advised to observe fast and make up the days lost.

The diseases in this group should be those in which fasting and its implications (restricted diet, restricted water intake, inability to administer medication for over 12 hours etc.) influence adversely recovery from illness or affect outcome of illness.

Time of full recovery can be assessed by history, physical, lab tests, imaging tools etc. and physician should believe that fasting and its implications now shall not cause disease relapse or impede convalescence. It is worth that physician extends the period of recovery on a longer-side to help patient to observe fast properly later.

(Prof. Muhammad Sultan Khuroo is Former Director, Professor and Head Gastroenterology and Chairman Deptt; Medicine Sher-I-Kashmir Institute of Medical Sciences, Soura, Srinagar, Kashmir)

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