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Guidance Notes on the Muslim Fast during Ramadan for Doctors

The Muslim fast during the month of Ramadan provides an opportunity for health professionals to promote health improvement amongst Muslims by offering lifestyle advice on topics such as diet and smoking cessation. It is important to recognise that the Muslim community, like any other, is diverse. This results in differences of perception and practice amongst Muslim patients. The start of Ramadan advances 11 days every year as it is based on a lunar calendar and will sometimes fall in the summer months, resulting in a more onerous fast than when it is in the winter months.

Fasting during Ramadan is intended as a discipline and requires abstinence from anything taken orally during the hours of daylight, each consecutive day for a month. This includes water and smoking. Bleeding will also preclude the fast for that day. Fasting is a requirement after puberty for all able bodied Muslims, of sound mind and good health, but there are concessions for those who are on a journey or are ill, as well as for women during menstruation, pregnancy and breastfeeding. The concessions range from a complete exemption from fasting, for example for insulin dependant diabetics, to a requirement to make up the fast at a later date, in the case of those who are travelling or have their periods. A charitable contribution as compensation can serve as an alternative to keeping the fast later.

Since the month of Ramadan is an important time across the community, many patients will endeavour to keep their fasts during this time. With some conditions, this can clearly be harmful. The concessions exist specifically to ensure that people do not fast where it would be detrimental to their health, and this is very reasonable advice to give to patients.

- For acute illnesses, fasts can be broken and made up later.

- For many chronic conditions (e.g. ophthalmic, dermatological, neurological) fasting may have no impact and can continue as normal. If oral medication is required, fasting can be facilitated by reducing dosing to once or twice daily. Topical medication, including patches are acceptable, but injections are not as they may draw blood.

- Fasting itself may have a physiological impact on diseases affecting the cardiovascular, renal and GI systems such as hypertension, renal impairment, or peptic ulcers. Although fasting is possible in many of these circumstances, it may not be well tolerated physiologically, particularly in older patients ¡V and these may be the very patients who are most adamant that they wish to perform their fasts. In some cases where a chronic illness has taken a long while to stabilise and maintain, adjusting medication around the hours of fasting may simply be impractical and potentially harmful.

- During pregnancy and breastfeeding, the mother's nutrition and hydration are paramount and, whilst fasting is permissible, it is medically better for the mother to utilise the concession and compensate or make up the missed fasts.

- Physical examinations, including rectal and vaginal examinations do not invalidate the fast. Clinical investigations such as blood tests, or those requiring intravenous access or oral contrast would preclude the fast during those particular days. Where these are elective outpatient investigations, many patients may prefer to reschedule them outside Ramadan. Urgent investigations should clearly not be delayed.

Each situation needs to be judged on its own merits, in the context of the patient's observance of Ramadan. A comprehensive guide is not possible, but the examples above serve to illustrate that there is Islamic guidance to ensure that fasting is not prejudicial to a patient's health.

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