Doctors must balance risks of Ramadan fasting with significance of observance: study

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Meredith MacLeod , Staff

Published Thursday, May 2, 2019 6:34PM EDT

Last Updated Thursday, May 2, 2019 6:35PM EDT

Doctors caring for Muslim patients with mental health disorders should balance concern about the effects of Ramadan fasting on symptoms with an understanding of the spiritual significance of the observance, says a new study released Thursday.

There is little research into the effects of fasting on the management of mental health illnesses, says lead author Dr. Zainab Furqan, a resident physician at the Centre for Addiction and Mental Health in Toronto. She joined a team of researchers from Toronto, California, and the U.K. to produce the study published in Lancet Psychiatry.

Furqan says she was frequently encountering Muslim patients who were confused about whether mental health illnesses are included in exemptions from Ramadan fasting within the faith’s guidelines.

“There are exceptions for acute and chronic illnesses, whether they are physical or mental illnesses,” she told “Anecdotally, I know Muslim community and religious leaders had questions, too. So that sparked my interest.”

Physicians should understand how integral the observance of fasting from sun up to sun down during the month of Ramadan is to Muslims before advising patients about the possible effects on their medications and sleep patterns, says Furqan.

“It’s a deeply cherished and valued thing for Muslims, so these decisions are not black and white. These decisions are very nuanced,” she said. “Muslim patients need to be properly advised about the safety of fasting and doctors dealing with psychiatric disorders need to be prepared for these conversations.”

Fasting during Ramadan is considered obligatory for those who can do so and observance is one of the five pillars of Islam. Muslims who fast abstain from food and water from dawn to sunset. Depending on the location and the season in which it falls, Ramadan fasting can last between 10 and 20 hours. It typically lasts about 17 hours when it lands in the summer in Canada.

“Certainly the conversation can get complicated. A 10-hour fast can look very different from a 17-hour fast,” said Furqan, who is also a resident in the clinician sciences program at the University of Toronto.

Fasting exemptions are also made for women who are pregnant, nursing or menstruating, children, the elderly and people who are travelling.

The authors say many people who are exempt from fasting due to illness still choose to abstain from eating or drinking because of the spiritual significance of the observance. But fasting can be detrimental to the effectiveness of medications, which are often dosed according to meals and sleeping schedules and require hydration.

“If physicians believe that the patient is at high risk of deterioration if medications are changed or withheld, the patient should be advised not to fast,” said the authors.

Previous research has examined the effects of fasting on patients’ lithium levels. Lithium is an important drug in the treatment of mental health conditions. Studies have shown stable serum lithium levels in fasting times of 10 to 12 hours, “however, it is unclear how lithium levels might be affected during summer months in high-latitude countries such as Canada and the U.K., where the Ramadan fast can last up to 17 hours,” the latest study said.

Ramadan fasting has been consistently associated with disrupted sleep patterns and with the reduction of the rapid-eye-movement phase of sleep, the deepest time of sleep.

“If a patient is known to be particularly vulnerable to sleep disruptions as a trigger for severe illness exacerbation, they should probably be advised to refrain from fasting,” the authors said.

The researchers found four previous studies examining the effects of Ramadan fasting on patients with bipolar disorder. Two Moroccan studies found relapses in either depression or mania in previously stable patients. But two studies in Pakistan showed there was improvement in mania and depression during fasting times.

Research in Muslim-majority countries has shown a decrease in suicide rates during Ramadan.

“It seems to be likely because of increased social connections and activities and that people feel more connected and integrated,” said Furqan.

There is also evidence fasting can worsen eating disorders, although no large studies have been done.

Patients and physicians should more carefully monitor mental health symptoms during a time of fasting, and consider including a patient’s spiritual advisor in any decision-making conversations about fasting, the researchers said.

Ramadan is the ninth month in the Islamic calendar and is linked to the first sighting of the crescent moon. In Canada, it will begin May 6 at sundown and carry through to June 4.

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