Thursday, September 9, 2010

Ramadan, Fasting, and Health in Muslim and non-Muslim Majority Countries

Saudi and foreign Muslims break their fast at a collective daily meal served at the Dirah mosque at the end of the second day of Muslim holy fasting month of Ramadan in Riyadh, Saudi Arabia Thursday, Aug. 12, 2010. (AP Photo)

This is a vast topic, and certainly it is late in Ramadan to be addressing it, but I thought it might be useful, including for future reference, to at least introduce some ideas. I was further encouraged to complete this post by a recent one by Wafa' at My World and More, On Fasting. In it Wafa' quotes a useful article on BBC News by Nuala Close, Lead cancer nurse, Barts and The London NHS Trust, Some Muslims 'risking their lives' in Ramadan, on the health challenges for those who are ill and fast against medical and religious recommendations, or those who delay necessary surgery until after Ramadan. Wafa' also raises the issue of her own diabetic status, the difficulty of maintaining normal blood sugar levels, and the pressure to fast anyway--personal, social, and religious.

I commented there about medico-religious exceptions to fasting and will address them again below, after reviewing the norms of the Ramadan fast.

Orphans attend a briefing on the holy month of Ramadan, which is to begin Thursday in Dhaka, Bangladesh, Wednesday, Aug. 11, 2010. (AP Photo/ Pavel Rahman)

The Fast/ Sawm صوم

Requirements

Fasting, or sawm (fasting set by Islamic law; abstention) during the lunar month of Ramadan is one of the 5 Pillars of Islam. It includes taking nothing by mouth, either food or drink, during daylight hours, as set by recognized authorities on sunrise and sunset. It also includes abstaining from intoxicants like tobacco, and needless to say extra attention not to consume alcohol or recreational drugs, which are already forbidden. Sexual activity is also forbidden during daylight hours. One should avoid evil thoughts, lust, and vulgar language.

Increased spirituality, reflectiveness about one's faith and observances, prayer, holy readings, increased piety, and greater kindness, charity, and forgiveness are all part of the fast, and indeed part of its main purpose.The benefits of  the fast are primarily spiritual,  as atonement for sins, heightened piety, and greater participation in the Muslim community through shared iftars and communal prayers.

The fast is only valid if a mental or verbal intention (niyyah)  to fast is made. It begins after the adhan for fajr prayer (the call for dawn prayer) and ends with the adhan for maghrib prayer (the call to sunset prayer). The fast is customarily broken with dates and water, maghrib prayers are made and then the breakfast meal, or iftar is eaten. In the pre-dawn hours dinner, or suhoor, is eaten.

Sawm is not restricted only to Ramadan but may be a voluntary part of one's religious practices at other times. These times are prescribed as follows: each Monday and Thursday of a week; the 13th, 14th, and 15th day of each lunar month; six days in the month of Shawwal, the month following Ramadan, during which fasting is seen as worthy of particular reward; 9 Dhu al-Hijjah (the Day of Arafa or perfection of the religion of Islam); 10 Muharram (the Day of Ashura or mourning for the martyrdom of Prophet's grandson Hussein bin Ali plus 9 or 11 Muharram (for Sunnis only); frequently during the months preceding Ramadan, Rajab and Shaban; 1-10 Dhu al-Hijjah.

Fasting is forbidden during both Eids Al Fitr and Al Adha, on Fridays, and as a constant practice.

Exemptions

Exemptions are of 2 main types: those that do, and do not require one to make up missed days of fasting. Persons who are acutely ill, traveling, pregnant, or nursing (breastfeeding) are not required to fast, but must make up the days later. During menses, women must not fast, and must make up those days later, when not menstruating, and before the next Ramadan.

The very young and the very old are not required to fast, and not required to make up fasting days missed during Ramadan. Those with chronic illnesses which make fasting medically dangerous are not expected to fast or to make up the days. Should they be cured, or have their health restored, they are required to resume fasting.

Compensations and Penalties

Those who unintentionally, eg through forgetfulness, break their fast should continue without further compensation for their lapse. Those who break their fast intentionally but with reason should continue for the rest of the day, and add an extra day. Those who break their fast intentionally without good reason must make up the days and also pay a penalty, often in the form of providing iftar and suhoor for a certain number of Muslims in financial need, or the same for a certain number of days.

Accommodations

Work hours or duties may be modified to ease fasting, either at a broader social and even national level, or within a company or job description. Those who are at risk of dehydration because of their work are permitted to break their fast. Those requiring medication are permitted to take it.

Those living in circumpolar locations where day night cycles are abnormally long, follow set hours more reflective of the norms elsewhere.

An Afghan Muslim woman takes part in evening prayers during the Muslim holy month of Ramadan on August 13, 2010 in Kabul, Afghanistan. (Photo by Majid Saeedi/Getty Images)

Health Aspects

The physical, mental, and social aspects of health are interconnected, as evidenced by the bio-psycho-social model of medicine (also known as the Rochester Model), and observations on mind-body relationships by philosophers and physicians over the course of history. Most of us have also observed that we feel better when we are physically active, mentally engaged in pleasant thoughts, and socially active, sharing our lives with others.

Physical

Withdrawal syndromes

One can reduce the impact of withdrawal syndromes by preparing ahead, and in the month before Ramadan begins gradually decreasing one's use of caffeine, tobacco, and junk food. For caffeine withdrawal, taking a lot of fluids and using analgesics are both easier outside of Ramadan. Nicotine gum, or a prescribed patch for tobacco withdrawal are also aids, as long as they do result in decreasing the nicotine in the system over time. Reducing junk food intake helps to reduce the cravings for salt and sugar which they create, and to change a snacking habit before it becomes impermissible. Eating healthy balanced meals with sufficient protein for sustained energy over the hours between meals is even more important while fasting than it already is during normal patterns.

As many have suggested, and hoped, Ramadan can be a good time and incentive to quit these substance uses, abuses, and addictions completely. Behavioural change is easier to maintain once it has been broken for at least 21 days (because of new learned behaviours), after withdrawal syndromes are resolved (because of the physical aspect of the habituation and reduced cravings), and in circumstances that are different than the usual (because of the psychological and social patterns of use).

Long Days and Heat

As during this Ramadan and the ones in the near future, fasting will be for more hours per day due to summer sunlight, and in hotter conditions. Both these factors make the fast more difficult and more taxing for the body, particularly for appropriate hydration. As a result, physical activity needs to be monitored and adjusted more carefully too.

Muslim men relax as they wait to break their fast at Istiqlal Mosque in Jakarta, Indonesia, Friday, Aug. 13, 2010. Indonesia is the world's most populous Muslim country. (AP Photo/Dita Alangkara)

Acute and Chronic Illnesses

Those with acute medical illnesses, that is, new onset and time limited ones, should follow medical advice about suspending their fast until they have recovered. This is an important aspect of healing, preventing complications, and of preparation for and recovery from surgery.

Those with chronic, that is longstanding or longer term illness, or untreatable ones should also follow medical advice about fasting, given their state of health, the risk of triggering acute problems, or complications (temporary or permanent) which might result from their illness not being adequately managed during Ramadan. Those who suffer from illnesses which are particularly sensitive to changes in eating patterns, like Crohn's Disease, Ulcerative Colitis, Irritable Bowel Syndrome, and Diabetes, should be even more careful about choosing to fast. Diabetics in particular are at risk of permanent untreatable complications like blindness, peripheral neuropathy, and resistant infection if their blood sugars cannot be maintained.

For these people, wellness and fasting are not a question of will, discipline, or piety, they are biologically determined and largely beyond the sufferer's control They should be advised not to fast, and given emotional and social support not to. They could plan to provide charity, or iftars and suhoors for others as their way of recognizing the obligation to fast though unable to do so themselves.

For some Muslims, fasting is an extra challenge because of an eating disorder, at either a clinical (whether diagnosed or not) or subclinical (extra issues but not diagnosable)level. Eating disorders include anorexia nervosa, bulemia nervosa, AN-BN (both simultaneously, or on a spectrum, or over time), overeaters, undereaters, and grazers. The disruptions in eating routines of Ramadan may trigger or aggravate disturbances in eating patterns, which may not resolve without therapeutic intervention. Those who are diagnosed and in treatment should follow medical advice on fasting; and those who aren't should consult with a physician.

Exercise

Needless to say vigorous exercise followed by prolonged fasting is ill-advised, primarily for the problem of dehydration, as the water lost through sweat will not be replaced for a long time, and will result in headaches, increased thirst, and general malaise. However, fitness can and should be maintained.

Regular physical exercise, which is good for mental health as well, and an excellent social activity, can be shifted to night hours. One family member gets up extra early and goes jogging with buddies, then has suhoor with them in one of their homes, before each heads off to work. Another time for exercise of whatever type (indoor, or lit) might be after breaking the fast and before or after iftar. One other suggestion would be right before breaking the fast. Obviously exertion in the morning when one must wait long hours for rehydration and sustenance is ill-advised.

Going for a walk is a good digestive, and can be sociable, whether among those heading out together, those met along the way, or part of a regular social walking place like a "boardwalk" along the sea coast or corniche, or a regular urban promenade/ park where people normally go for evening strolls. In Muslim majority countries there are often outdoor evening activities and entertainments in the cities, which is another way to combine walking exercise and socializing. Walking to and from family visits where feasible is another option.

Respecting one's own limits, level of fitness, and current state of well-being is always advisable for any physical activity or sport, in order to prevent injury, perform well, and enjoy the experience.

Indian Muslims wash themselves as they get ready to offer prayers on the first day of the Muslim holy month of Ramadan at Jama Mosque in New Delhi, India, Thursday, Aug. 12, 2010. (AP Photo/Saurabh Das)

Psychological

Ramadan is a way of learning self discipline and restraint which can carry over to other aspects of ones life, such as the discipline to face challenges, persist, remain resilient. Knowing one can and has fasted for the month of Ramada can be a source of psychological strength, and give confidence in one's ability to handle other strains. I have witnessed Muslims who use it as a positive psychological defense mechanism in the face of discrimination.

On the other hand, the immediate effects of fasting during Ramadan can have negative psychological effects due in large part to the physical strain, and hypoglycemia in particular. Sleep deprivation and disrupted sleep cycles are also major factors, as well as the psychological symptoms of withdrawal syndromes. The negative feelings can include apathy, discouragement, sadness, depression, self doubt. Those who break their fast for whatever reason may experience feelings of guilt, shame, and self-recrimination. Cognition may be slowed, and attentiveness impaired. Activities, including exam taking should be adjusted according to optimal times for peak performance, usually in the morning.

General irritability can be a main phenomenon for some and lead to unpleasant interpersonal exchanges. This has been studied by psychiatrists as one of the negative psychological manifestations during Ramadan.

Social

Ramadan offers a time of particular social well-being of community spirituality, communal prayers, shared iftars, and social visits.

For Muslims in Muslim majority countries there is the benefit of a total experience within the community; understanding, shared challenges, and accommodations in work hours, etc. For Muslims in non-Muslim majority countries there are the challenges of fasting while the main part of the community isn't. Some may be used to it because they are raised in mixed religion countries with a high Muslim demographic. For others from very high Muslim majority countries it may be totally new. Even those with some experience of fasting in low Muslim majority or non-Muslim majority countries may find fasting in Western countries where the population is very low as a percentage, or in settings where they may be the only Muslim, is an extra challenge.

Non-Muslims can help by being intuitive, understanding, and respectful: intuitive about who might be fasting and may not want to say; understanding of signs of fatigue or lower attentiveness and changes in day rhythms; and, respectful of not eating, drinking, smoking, or "being lascivious" (eg save the flirt for after sundown) during fasting hours. Accommodations are most often easy and appropriate whether in the workplace, educational institutions, or social events among friends, or clubs with a regular membership.

Canadian public schools with Muslim students often hold prayer activities and religious discussions led by an adult Muslim volunteer in a separate room during the lunch hour; teachers who have a special class party planned will either schedule it before or after Ramadan, or hold a second one when all are able to participate; and, schools with an interfaith approach to holidays will take the opportunity to educate all students about Islam just as they do about Christianity, Judaism, Hinduism, and other world religions.

Palestinian security officers pray in the street in the West Bank town of Nablus during the Muslim holy month of Ramadan, Monday, Aug. 16, 2010. (AP Photo/Nasser Ishtayeh)

Hubris and Nemesis

It is sad to say, but a universal phenomenon, that some in all religions take their piety so seriously as to be guilty of pridefulness about it. This is worrisome, because the price of this pride can be high in terms of compromised health for those who fast against medical advice and ignore Allah's exemptions and compensations.  Complications, permanent disability, and death are too high a price to pay for the ability to say one fasted in the face of illness, or delayed care until after Ramadan. "Pride goeth before the fall"; and, as humility is a virtue in all religions, including Islam, this particular form of pridefulness is especially dangerous.

A Special Role for Muslim Physicians, Medical Ethicists,
Health Care Providers, and Community Leaders

In light of the type of self-harming behaviours that some ill people impose on themselves, or are pressured in to adopting during Ramadan, it seems to me that Muslim physicians, medical ethicists, health care providers, and community leaders need to make a more public effort to advise people and popularize through the traditional and new media the idea that it is better for people to respect the exemptions that Allah has provided than to compromise their health through fasting. All should be reminded of the alternatives to fasting that Allah has provided for; the Islamic injunctions to care for one's health and to seek appropriate medical care and scientific knowledge about health; and that the support of family and friends in this is crucial to the person who wishes to fast but really should not.

Indian Muslims gather during Friday Prayers at a mosque in Allahabad, India, Friday, Aug. 13, 2010. (AP Photo)

Your comments, thoughts, impressions, advice, experiences?

*Photos are from Scenes from Ramadan, where more can be viewed.

7 comments:

Souma said...

abstaining from food makes me schedule my day around prayers instead of meals (as a muslim should anyway) but hypoglycaemia gets to me, every single day of ramadan! i try to sleep it off, nothing else i can do. cant focus and gloomy thoughts keep forming...

Shafiq said...

There was an article on the BBC website early on in Ramadhan about this exact issue. Apparently, many Muslims are putting of major life-saving surgery until after Ramadhan and others are fasting even though they're forbidden from doing so due to their health.

On the other side of the spectrum, I know a couple of Muslims who don't fast because they simply can't (won't?) give up fasting.

oby said...

I have a question...

When I go to an Indian restaurant and eat a big meal at lunch I am not hungry AT ALL for the rest of the day...not even until bedtime. It holds me for hours.

What I am wondering is why can't people stock up really really well on very filling foods early in the day before sunrise...by the time dinner comes they should be hungry...even very hungry but famished? I am not so sure. Wouldn't that make the process easier? Just wondering.

Susanne said...

Really nice pictures and interesting information. Thanks for sharing!

Shafiq said...

Oby,

Unfortunately, it doesn't work like that. During the precious few hours where you can eat, you don't feel very hungry. During Suhoor (the period before starting the fast) I could barely keep down a bowl of cereal and a cup of tea. And then when you break your fast, all your ideas about having a giant five-course meal quickly disappear.

Wendy said...

Shafiq, I think you might be an exception. I know that my Saudi in-laws manage to stuff themselves pretty good both during Suhoor and then again in the evening. :)

Omar farukh said...

thanks for sharing

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