When caring for any patient, having a basic understanding of their culture and values can go a long way toward building trust and improving the patient’s experience and outcome. This rings especially true as we enter Ramadan, considered the most sacred month of the year in the Muslim calendar. A basic understanding of Ramadan will help promote shared decision-making with improved clinician-patient partnerships, leading to better care for sick Muslim patients during the holy month.
Not everyone may know the intricacies of Ramadan, which takes place this year from April 2 to May 2, and what the observance entails, so a brief breakdown may benefit health care workers. Ramadan is a monthlong religious observation during which Muslims fast from dawn to sunset; worship; pray; give generously to charity; self-reflect; and focus on strengthening character and self-control. Ramadan culminates with celebrations of Eid al-Fitr.
When treating Muslim patients, one should remember to never make assumptions about their practices; rather, one should ask the patient about their observances. It is also important for clinicians to understand the depth and breadth of the Muslim experience in the U.S. The terrorist attacks of 9/11, the subsequent wars, and growth of Islamophobia in some segments of society have contributed to shaping the Muslim experience and serve as an important social determinant of health. Some health care workers may have developed implicit biases toward Muslims and may be unaware of the suboptimal care they are providing to their Muslim patients, particularly during Ramadan’s vulnerable period of fasting.
Ramadan fasting is from dawn to sunset, with abstinence from food, drink, smoking and sexual intercourse during fasting hours. Islam adheres to a 12-month lunar calendar; Ramadan is the ninth month and is one of the five pillars of Islam. The Islamic year is approximately 11 days shorter than the Western Gregorian calendar, so Ramadan occurs at different times of the calendar year. Ramadan in the winter leads to shorter fasts because of the shorter days. Summer Ramadan fasts are much longer, with thirst being a greater challenge for many. Fasting Muslims usually eat a suhoor meal to begin the fast at dawn, and an iftar meal to break the fast at sunset. Exemptions to fasting include anyone who is traveling, pregnant, breastfeeding, or menstruating; prepubertal children or those with acute or chronic illnesses that may worsen with fasting are also exempt.
Despite these exemptions, some patients may still fast. Clinicians should be aware that patients can later make up a day of fasting if they were not able to participate in the fast. They can also feed someone who is less fortunate to make up for not fasting. There are also procedures that may invalidate the patient’s fast. Clinicians should be aware of these instances, since invalidating the fast may create significant distress for the patient. Invalidating procedures include the consumption of oral medications; using asthma inhalers; most endoscopic procedures; undergoing general anesthesia; receiving IV fluids; parenteral nutrition; and intentional vomiting. It is important to partner with the patient and their family to go over these and other procedures that may invalidate fasting. In some cases, one may need to alter the timing of the medication administration to accommodate for fasting hours. Most Muslim scholars consider the following allowed: ear, nose, and eye drops; rectal suppositories; enemas; and blood transfusions.
When clinicians are equipped with the theological understanding and appreciation of different jurisprudence schools, then they are better positioned to present their patients with more options, make shared and partnered clinical decisions, and schedule these “gray area” procedures and medication during non-fasting hours or after Ramadan.
Beyond just the physical, Ramadan is also a spiritual mission. Patients may have disturbed sleep cycles from waking up early for the pre-dawn meal and tending to life’s obligations such as work or school on a fasting stomach. The holy month provides an opportunity for clinicians to team up with the individual patients to achieve specific health goals. It is important for health care clinicians to educate fasting patients on how to hydrate and drink enough fluids, eat well-balanced nutritious meals, maintain good sleep hygiene, fast in a safe manner, and maintain proper adherence to medications and treatment of comorbid conditions. Taking advantage of the discipline and self-control that Ramadan demands, clinicians can help fasting patients to achieve lifestyle changes like quitting smoking or alcohol and maintaining meaningful supportive relationships with family and friends. Patients should be encouraged to maintain the healthy habits established during Ramadan into the post-Ramadan period and beyond.
With comorbid chronic conditions, Muslim patients risk such serious complications as dehydration, hypoglycemia, hyperglycemia, and diabetic ketoacidosis. Fasting Muslims may not adhere to prescribed medication, and may refuse treatment or diagnostic tests during Ramadan that could invalidate the fast. Muslims with advanced diabetes are exempted from fasting, but some may still choose to fast. The International Diabetes Federation created risk-stratified guidelines for fasting in people with Type 1 or 2 diabetes mellitus that takes into consideration religious knowledge to make medical recommendations. High-risk categories are strongly discouraged from fasting. Recommendations include a pre-Ramadan medical assessment to check the latest HbA1C, and a consultation that educates the patient on diabetes management during Ramadan — which consists of proper diet, nutrition, exercising while fasting, and recognition of hypoglycemia and hyperglycemia symptoms. Patients are advised to eat multiple small meals between iftar and suhoor instead of one big meal at iftar; modify medication dosage; check blood glucose multiple times throughout the day; and to immediately break their fast if their blood sugar falls under/above certain thresholds or if they become symptomatic of hypoglycemia or hyperglycemia.
Patients with unstable angina, decompensated heart failure, recent cardiac surgery or myocardial infarction are also discouraged from fasting. Heartburn, bloating, and indigestion are common gastrointestinal symptoms that occur during fasting and can be due to excessive eating late at night. They can be avoided by eating small meals and staying away from trigger foods. Patients with active peptic ulcers and uncontrolled asthma should also be discouraged from fasting. Patients with renal conditions or on dialysis are advised to increase fluid intake and schedule dialysis sessions on non-fasting days.
Understanding the interplay between fasting and these medical conditions will help the medical team ensure safe, fast, and proper care of patients. These recommendations are not all-inclusive — one might consider consulting with local religious leaders either in one’s hospital or in the community. The vast cultural diversity of the American Muslim community should also be appreciated in this regard, as the admixture of regional cultural practices with religious theology adds further richness to Ramadan norms and may require further consideration.
How do you provide care to your Muslim patients during Ramadan? Do you have additional strategies and considerations to offer? Share your thoughts in the comments below!
Mill Etienne, MD, MPH, FAAN, FAES, is associate professor of neurology and of medicine at New York Medical College, where he teaches multiculturalism and medicine and is also the vice chancellor for diversity and inclusion and associate dean of student affairs.
Adil Afridi, MS, is a fourth-year medical student at New York Medical College, with an interest in multiculturalism in medicine, and Islamic history, civilization, and theology. Upon graduation, he will begin residency training in diagnostic radiology.
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