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Each year as Ramadan approaches, millions of Muslims brace themselves, physically, mentally, and spiritually, to fulfill the perennial obligation of fasting and bask in the saintly ambience fasting creates in and around the observers of this elemental ritual of Islam. But among those eager millions there are many whose desire to fast is eclipsed by a myriad of health problems that render them physically unfit to fast even though they may be spiritually geared up.
However, Allah, out of His mercy, has good news for this category of legally responsible Muslims. In the same verse in which Allah pronounced the obligation of fasting, He exempted from this duty, either permanently or temporarily, those who are hindered from it by forbidding physical ailments, old age, travel, etc. Allah Says (what means):
“The month of Ramadan [is that] in which was revealed the Qur'an, a guidance for the people and clear proofs of guidance and criterion. So whoever sights [the new moon of] the month, let him fast it; and whoever is ill or on a journey - then an equal number of other days. Allah intends for you ease and does not intend for you hardship and [wants] for you to complete the period and to glorify Allah for that [to] which He has guided you; and perhaps you will be grateful.” [Quran 2: 185]
In the following, we will provide a general medical overview of the different types of diseases and health conditions fasting persons or those intending to fast might be afflicted with, and to what extent do these diseases and conditions affect their ability to fast, and what are the recommendations medical doctors offer in this regard.
Deferred fasting and atonement
1. The traveler
2. The ill
3. Those for whom it may be difficult rather than easy.
4. Menstruating female: Menstrual bleeding causes physical impurity [Quran 2:222]. Some might even feel physically weak and emotionally depressed. Some degree of pain and discomfort is very common. During her period, a woman should not fast; she should start fasting only when she is clean. She is required to make up the days she missed at a later date.
5. Pregnancy
6. Breast feeding mothers: Fasting may lead to reduced milk production by the mother and if the baby is dependent solely on its mother’s milk, it may critically affect the baby’s health. If the circumstances call for, mother should defer fasting for later days or make alternative arrangements, e.g., atonement.
7. Disability due to old age, e.g., simple physical weakness which can be complicated by calorie deprivation or dehydration. Since old age is irreversible, regular atonement will be necessary.
8. Chronic irreversible pathological conditions e.g., old age dementia or Alzheimer’s disease may need regular atonement.
9. Psychological disorders: depending on the reversibility, persons suffering from these disorders may need temporary or permanent atonement.
10. Any chronic illness where there are less chances of recovery and fasting may further complicate the situation e.g., some form of Diabetes Mellitus or any other condition that requires frequent medications and monitoring of patient’s condition, atonement will be the alternative means.
It is noteworthy that there is no permanent exemption from fasting.
Pregnancy and Ramadan fasting
To understand the effect of fasting on pregnancy, one must have at least basic knowledge about the global changes that happen to a pregnant woman. A detailed account, however, is available from any textbook of obstetrics. For the purpose of this article, only a brief reference has been made to the chapter 13, Maternal Adaptation to Pregnancy, p. 223 and chapter 14, Prenatal Care, p. 235, of Thomas R. Moore’s book Gynecology & Obstetrics.
Maternal adaptation to pregnancy:
Although pregnancy is considered to be a physiological condition to the patient, the physical and psychological changes that occur in pregnancy may be confusing and may be interpreted as pathological.
Near the end of nine months of pregnancy, a woman may find that she has gained an average of 22 to 26 lbs. in weight, that she experiences swelling of her face, hands and ankles, and that she is short of breath on moderate exertion. She may experience urinary incontinence, constipation, and hemorrhoids, as well as difficulty in standing for prolonged periods because of lower-back pain and sciatica. Sleep may be interrupted several times a night because of uterine discomfort and the need to empty her bladder. All these changes arise from the orderly bodily changes dictated by the rising levels of hormones elaborated by the placenta and by the growth of the fetus.
Recommended calorie intake in normal pregnancy
During the normal course of pregnancy, an average of 80,000 kcal is required above the energy requirement of the non-pregnant state. This amounts to an additional 300 kcal/day–– which can be provided by one pint of low fat milk, one peanut butter sandwich, or less desirably one can of soda and 10 French fries (Hytten FE, Leitch I. (1971), Physiology of Human Pregnancy). Current recommendation for total dietary intake in healthy, adult pregnant women is 2000 2700 kcal/day.
Normal pregnancy weight gain
Average pregnancy weight gain in North America is 33 +/- 12 lbs. Nevertheless, significant variation among individuals is expected because of differences in height, body type and pre-pregnant weight.
Weight gain and perinatal mortality
In North America maternal weight gain is a minor contributor to pregnancy outcome; therefore, dietary recommendations for pregnant women should be individualized.
Effect of calorie restriction on pregnancy outcome
Contrary to ordinary belief, even severe calorie restriction has minimal impact on pregnancy outcome. During WW2, calories provided to people in the Netherlands were reduced from 2000 kcal to 70 kcal/ day. This resulted in no impact on first and second trimesters, and only a small reduction in birth weight of babies born to mothers in the third trimester from 3370 to 3150 g (a drop of 220 g, or 6%). However, no cases of stillbirth, prematurity, or lactation were recorded.
Pregnancy nutritional supplementation:
- Calories: 2000-2700 kcal/day
- Protein: 30g additional
- Iron : 60mg/day
- Folate : 400 800 micg/ day
- Calcium : 400 mg additional
Observations:
1. There is tremendous amount of physical and psychological adaptations that the body need to make to accommodate pregnancy. The pregnant mother constantly lives in fear not about herself but about the health and future of the unborn baby. Out of love for some one that she has not yet seen, she is ready to sacrifice anything and everything for the wellbeing of the unborn.
2. Recommended amount of total calories per day is 2000-2700 kcal.
3. Average daily calorie requirement of growing fetus is 300 kcal. This amount, however, will vary according to the gestational age of the fetus. Requirement is much more during second and third trimesters but does not call for a significant increase in the total calorie intake of the mother.
4. Except in cases of extreme malnutrition and obesity, marked alteration in maternal dietary habits is not likely to improve pregnancy outcome.
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