Fasting for Patients with Gastrointestinal Disorders
Abdul Monem Swied, MD, FASGE
Associate Professor
Sophia Dar, MD
Fellow
Hafiz Muhammad Sharjeel Arshad, MD
Assistant Professor
Muataaz Azzawi, MD
Fellow
Affiliation:
Gastroenterology Division, Department of Medicine
Southern Illinois University- School of Medicine
Springfield, Illinois
Introduction:
Intermittent fasting (IF) has gained popularity over the past few years due to its overall positive effects on health, such as improving blood pressure, heart rate, cholesterol levels, and glycemic control (1) Li Z et al 2021.
Ramadan-associated intermittent fasting (RF) is a unique form of fasting practiced by 1.9 billion Muslims worldwide during the holy month of Ramadan.
Between dawn and dusk, Muslims refrain from eating, drinking water, smoking, and having sexual intercourse. The vast majority of Muslims take this religious obligation very seriously, and it has been practiced for over 1,400 years, as decreed by the Quran.
There are some exceptions to RF. Prepubertal children, women during their menstrual period or postnatal bleeding, travelers, pregnant or breastfeeding women, the mentally unfit, and those with acute or chronic illness are exempt from fasting. (2) Abolaban H et al 2017.
Since RF is a dietary modification, chronic medical conditions affected by dietary changes, such as diabetes and gastrointestinal (GI) diseases, may be exacerbated in patients with these chronic illnesses who are observing the fast.
RF takes place between dawn and sunset. This change affects eating patterns, sleeping patterns, and physical activity patterns. This change alternatively affects the circadian rhythm hormones, including cortisol, insulin, leptin, ghrelin, growth hormone, prolactin, sex hormones, and adiponectin. (3) Lessan N et al 2019.
Ramadan and Gastrointestinal Benefits
One study by Su et al. reported significant remodeling of the gut microbiome during Ramadan-associated intermittent fasting (4) Su J et al 2021
The principal finding is that RF has a beneficial effect on gut hormone levels for leptin, glucagon-like peptide-1 (GLP-1), peptide YY (PYY), and cholecystokinin (CCK) in males with obesity (5) Zouhal H et al 2020.
RF provides many health benefits to the gastrointestinal system by restructuring the gut microbiome, altering the levels of gut hormones, and essentially cleansing the gastrointestinal tract.
Pre-Ramadan Counseling
Counseling practices during Ramadan can be challenging for providers. Asking about the patient's history, lifestyle changes, values, previous fasting experience, medication regimen, assessing fasting length, and climate can allow clinicians to stratify patients into very high-, high-, moderate-, or low-risk categories.
Clinicians may counsel high-risk and very high-risk patients regarding concerns with health risks and worsening of chronic medical conditions, essentially discouraging these patients from fasting. Low - or moderate-risk patients may fast if lifestyle and medication issues have been addressed. Detailed counseling that addresses the risks of fasting is critical in provider-patient interactions.
Muslims who are exempt from fasting are pregnant or breastfeeding women, women in their menstrual period or postnatal bleeding, travelers, elderly individuals who cannot handle fasting, mentally disabled individuals, prepubertal children, and those with an acute illness that will worsen with fasting 2) Abolaban H et al 2017.
Being well-hydrated, maintaining a healthy diet, structuring exercise between sunset and sunrise, altering drug regimens, and avoiding practices that result in rapid weight changes may provide a helpful basis for initial advice for informing fasting patients.
Medication Recommendations
Fasting can also affect the absorption of medications for gastrointestinal disorders. Given that Muslims are required to refrain from food and liquids and the consumption of oral drugs while fasting, the efficacy of and adherence to drug regimens may be compromised during Ramadan. The typical fasting day can last up to 18 hours, which can be problematic as patients may elect to forgo their medicine, skip doses, or combine multiple doses without medical advice from their physician. One or two daily doses are the most common drug regimens used during Ramadan and are typically much easier to follow than medications with multiple doses. Providers should consider these changes in medication dosing and bioavailability and offer recommendations to improve drug dosing and help patients comply with their treatments during Ramadan fasting.
Dietary Recommendations
When physicians meet Muslim patients during Ramadan, they should remember that their dietary habits are altered compared to non-Ramadan months, especially regarding meal timings and dietary content. In addition to these changes, each Muslim patient may have a cultural background with unique traditional cuisine and dishes with varying nutritional content. The patient's eating habits and nutrient intake should be assessed during and after Ramadan to avoid foods that trigger gastrointestinal symptoms. It is possible to link dyspepsia, bloating, indigestion, and heartburn to food intake during fasting. This may allow providers to have a candid discussion with patients regarding which foods may be triggering the patient's symptoms. The goal is to emphasize a consistent and persistent healthy diet with wholesome foods from diverse food groups and an appropriate amount of protein.
Ramadan-associated Intermittent Fasting and Gastrointestinal Disorders
Patients with a high risk of severe health complications are discouraged from fasting. Therefore, data on the consequences of fasting in patients with certain conditions may provide a better understanding for physicians and Muslim patients to make informed health decisions.
Table 1 summarizes the recommendations mentioned below for fasting.
Inflammatory Bowel Disease (IBD)
Inflammatory bowel disease is a broad term used to describe inflammation of the gastrointestinal tract. It can be further subclassified into Crohn's disease and Ulcerative colitis. Crohn's disease is classically seen with skip lesions and transmural inflammation of the intestinal mucosa involving any part of the gastrointestinal tract with complications involving fistula, obstruction, nutritional deficiency due to malabsorption, and the risk for kidney stones. Ulcerative colitis is defined by superficial and continuous colon ulcerations with complications such as toxic megacolon and a higher risk of colon cancer. Studies have found no statistically significant difference in their self-reported symptoms before and after Ramadan and no correlation between the number of days fasted and disease severity (which was based on self-reported symptoms). Ramadan fasting posed no significant risks to patients with mild and uncomplicated IBD. The final recommendations offered by these studies include thoroughly counseling IBD patients on the possible risks of fasting during Ramadan and allowing them to observe Ramadan with precautions and vigilance. Elderly UC patients require special attention.
Peptic Ulcer Disease
Gastric or duodenal ulcers cause peptic ulcer disease (PUD). Common causes of PUD include Helicobacter pylori infection and long-term use of non-steroidal anti-inflammatory drugs (NSAIDs) or aspirin. Based on evident correlations between peptic ulcer disease and dietary intake, Ramadan fasting may impact the symptoms and risk for complications of PUD.
It is recommended that patients with epigastric pain take precautions if they choose to fast, such as consulting their physician or taking anti-secretory agents such as proton pump inhibitors (PPIs) to reduce stomach acidity. It is preferabe to take medications that are long acting to make compliance with fewer pills taken at night.
Essentially, studies found that gastric ulcers may have impaired healing associated with RF. There may be more surgical interventions for peptic ulcer disease patients in fasting months compared to non-fasting months. Regarding duodenal ulcers, studies have found that RF exacerbates duodenal ulcer symptoms and incidence. Within this discussion, emphasis should be placed on the importance of careful self-monitoring of symptoms under the close supervision of physicians. Providers should counsel patients so they understand the risks of fasting and when to seek medical attention.
Gastroesophageal Reflux Disease
GERD patients who fast during Ramadan can see improvements in their symptoms through positive changes in diet behavior, including the lack of smoking and alcohol consumption. However, suppose they are eating at high volumes before sleeping or ingesting foods or drinks that can exacerbate GERD symptoms. In that case, their symptoms might be improved by safely taking a proton pump inhibitor before the initiation of fasting during Ramadan. It is also recommended to avoid foods and beverages that trigger acid reflux symptoms. One recommendation to alleviate GERD occurrences during Ramadan is a Mediterranean diet.
Regarding GERD patients who experience symptoms during the fasting day, it would be prudent for physicians to suggest proton-pump inhibitor (PPI) administration 30-60 minutes before the iftar (sunset) meal (on an empty stomach). An alginate or an alginate-antacid combination is a recommended drug alternative that allows the patient to maintain speed and relieve postprandial reflux more quickly. These medications can be taken after an iftar meal and have been shown to reduce gastric acidity and reflux more quickly than omeprazole, a PPI.
In summary, available literature thus far points to the consensus that fasting with GERD is ultimately safe.
Upper Gastrointestinal Bleeding
Due to the dangerous nature of upper gastrointestinal bleeding (UGIB), it is essential to gauge whether fasting is suitable for those at risk for UGIB. Prophylactic measures should be taken for those at risk for peptic ulcer disease. Several studies pointed out that duodenal ulcers may have symptom flares during Ramadan. However, this correlates to duodenal ulcers classically being a more common source of UGIB. Ramadan fasting can be dangerous for patients with active peptic ulcers due to the feared hemorrhage complication. Therefore, patients with active GI bleeding should refrain from fasting and seek medical attention.
Liver Diseases
Metabolic dysfunction-associated steatotic liver disease (MASLD) occurs commonly with comorbidities such as obesity, high cholesterol, and type 2 diabetes, as the name implies. Most people with MASLD do not experience any symptoms. In rare cases, those with MASLD may experience fatigue or vague right upper abdominal discomfort.
In addition to the potential metabolic benefits of fasting, limiting food consumption during Ramadan fasting can help reduce cholesterol levels, improve blood lipid profiles, and even lead to weight loss. With reduced BMI cholesterol levels and beneficial metabolic changes, Ramadan fasting may improve MASLD and other components of the metabolic syndrome.
Patients with liver transplants who have stable graft function and do not suffer from cirrhosis could safely observe Ramadan with special counseling with their hepatologists, especially about the immunosuppressive drugs that all liver transplant patients take.
Fasting during Ramadan is deemed suitable for patients in the early stages of liver cirrhosis without decompensation. However, for individuals with decompensated liver cirrhosis, it is advisable to refrain from fasting due to the accelerated onset of starvation resulting from diminished hepatic glycogen synthesis and storage during the postprandial state. To mitigate fasting duration for patients with decompensated liver cirrhosis, it is recommended to maintain a maximum interval of 3-4 hours between nutritional intake while awake. Additionally, to minimize nocturnal fasting time, incorporating an early breakfast and a late-evening snack into their dietary routine is advisable.
Studies have suggested that fasting is potentially beneficial for patients with MASLD. Cirrhotic patients with Child-Pugh class A may fast with close observation, but Child-Pugh B or C patients should not fast due to the higher risk of complications.
References:
1. Intermittent fasting. Li Z, Heber D. JAMA. 2021;326:1338. )
2. Muslim patients in Ramadan: a review for primary care physicians. Abolaban H, Al-Moujahed A. Avicenna J Med. 2017;7:81–87
3. Energy metabolism and intermittent fasting: the Ramadan perspective. Lessan N, Ali T. Nutrients. 2019;11)
4. Remodeling of the gut microbiome during Ramadan-associated intermittent fasting). Su J, Wang Y, Zhang X, et al. Am J Clin Nutr. 2021;113:1332–1342).
5. Effects of Ramadan intermittent fasting on gut hormones and body composition in males with obesity. Zouhal H, Bagheri R, Triki R, et al. Int J Environ Res Public Health. 2020; 17)
