Fasting for Patients with Hypertension
Randa Soukieh, MD
Family Medicine
Zaiba Jetpuri, DO, MBA, CPH, FAAFP
Family Medicine
Rashed A. Alfarra, MD
Internal Medicine, Nephrology and Critical Care Medicine
Introduction:
Every year, hundreds of millions of Muslims worldwide observe the sacred tradition of Ramadan, a month-long period of fasting from dawn to dusk. This religious practice brings about significant changes in diet and lifestyle for those who participate. Consequently, understanding the impact of Ramadan fasting on health, particularly on blood pressure, becomes imperative. Hypertension, a condition characterized by sustained elevated blood pressure levels, affects an estimated 1.28 billion adults globally, making it a prevalent health concern. In the United States, hypertension affects 32 to 46% of US adults with prevalence increasing by age, but often the diagnosis can be delayed, so it is known as a “silent killer”. Despite its silent nature, hypertension poses serious risks, including heart attack, stroke, and kidney disease. Identifying and managing high blood pressure is crucial, especially considering its asymptomatic nature for the most part.
For Muslims, the obligation to fast during Ramadan presents unique challenges, particularly regarding medication adherence and blood pressure management. This chapter aims to address these challenges by discussing strategies for adjusting medication regimens, monitoring blood pressure, and ensuring the safety of fasting for individuals with hypertension.
This chapter seeks to provide guidance to empower patients in navigating the intersection of religious observance and medical care during Ramadan, but in no way is this a substitute for medical advice and individual patients should always seek advice from their physicians.
What is high blood pressure?
High blood pressure is a condition that puts you at risk for heart attack, stroke, and kidney disease. It does not usually cause symptoms. However, some symptoms of elevated blood pressure include headache, blurry vision, chest pain, shortness of breath, dizziness.
Typically, blood pressure readings consist of two numbers: the systolic pressure (when the heart contracts) and the diastolic pressure (when the heart relaxes). Medical guidelines categorize blood pressure into normal, elevated, stage 1 hypertension ranges based on these numbers. While various medications exist to manage hypertension effectively, adhering to prescribed treatments remains essential for optimal control.
●Normal – Top number of 119 or below and bottom number of 79 or below
●Elevated – Top number between 120 and 129 and bottom number of 79 or below.
●Stage 1 – Top number of 130 or above and/or bottom number of 80 or above.
Blood pressure is acutely affected by changes in diet, physical activity, stressors, and sleep patterns.
General Recommendations and Precautions
In Ramadan, Muslims have 2 basic meals during the day, one is predawn (Suhoor) and one is after sunset (Iftar). This dietary change is the key change in their lifestyle for the month which could impact blood pressure as intake could be reduced/adjusted and timing of meals are different. However, Muslims may also have a different level of physical activity and different sleeping pattern during the month.
Multiple studies showed that fasting Ramadan has a positive effect on the vast majority of the fasting hypertension patients (better blood pressure control) and help patients adhere to their medications better. Ramadan also presents an ideal time for gradual weight loss, as even modest reductions, such as five percent of body weight, have been shown to normalize blood pressure levels. Caloric restriction not only reduces body weight, but it has been shown to improve cardiovascular risk factors and improve insulin sensitivity and systemic inflammatory states.
Nutrition:
During Ramadan, it is crucial to maintain proper hydration by consuming plenty of fluids and unsweetened natural juices at Iftar, thereby mitigating thirst, dehydration, and associated complications. Incorporating fruits and vegetables into daily meals is essential as they provide potassium, aiding in the control of high blood pressure. It is advisable to avoid high-fat dishes. Nuts can provide protein and healthy fats. It is advisable to avoid stimulants like coffee and caffeinated soft drinks to minimize caffeine intake because they serve as diuretics and can lead to fluid loss later.
High-sodium foods such as salted nuts and pickles should be replaced with fresh green salads to prevent hypertension. Additionally, including grilled fish rich in Omega-3 fatty acids, such as salmon and sardines, at least twice a week can help regulate blood pressure and prevent cardiovascular diseases. Red meat and poultry should be consumed in moderation, while low-fat dairy products are recommended due to their calcium content, which contributes to blood pressure regulation and bone health. Fried foods, processed meats and cheeses containing high sodium concentrations, such as sausages and mortadella, should be avoided.
Licorice drinks (juice common in some middle east countries) should be limited to 1 cup a day as in excess it can cause blood pressure elevation. Also olives, while high in good fat, may have too high of a salt content so should be limited to no more than 4-5 per day.
Portion control should also be regulated because often people may eat poorly during the evenings when it is time to break fast. Often there are celebratory foods during the evening meal and after a day of fasting, people may eat hundreds of calories in a hurry. It is advisable to eat a small portion or a few dates with a glass of water initially to start the meal. Once the body registers the metabolic change, then it is likely to need less food intake during the meal.
Physical Activity:
Regular blood pressure measurements and continued exercise during Ramadan, can aid in blood pressure regulation. It is essential to ensure proper hydration (as discussed above) if performing aerobic exercise. A good rule of thumb to consider is cutting back on intense cardio workouts or heavy weight training exercise by half of the intensity and duration.
Smoking:
Individuals with hypertension should view Ramadan as an opportunity to quit smoking, as nicotine significantly raises systolic pressure and escalates the risk of heart attacks and strokes.
Medications
Dehydration, volume depletion, and a tendency toward hypotension may occur with fasting during Ramadan, especially if the fast is prolonged and is associated with excessive perspiration. Hence, the dosage and/or the type of antihypertensive medications may need to be adjusted to prevent hypotension (low blood pressure).
Below is a list of the most common types of medications given to people with high blood pressure:
v Calcium channel blockers
o Amlodipine: one of the most commonly prescribed medication, can be taken during suhoor in Ramadan
o Nicardipine, Nifedipine and Diltiazem are other common calcium channel blockers used for hypertension, these medications available in multiple times during the day dosing and extended-release dosing, it is recommended to discuss with you physician before Ramadan to be switched to the extended-release formula in preparation for fasting.
v ACE inhibitors or Angiotensin Receptor Blockers ("ARBs")
o Lisinopril and Losartan are the most common ones, they are usually once a day medication and can be taken same time everyday either with suhoor or with iftar.
v Diuretics (“water pills”)-
o Hydrochlorothiazide (HCTZ) is a commonly prescribed medication for hypertension, it is a weak diuretic, and it is usually prescribed once a day and can be taken during iftar in Ramadan.
o Furosemide (Lasix) is a stronger diuretic and dose should be adjusted during Ramadan to avoid dehydration; adjustment should be discussed with your physician.
v Beta blockers
o Metoprolol, Carvedilol, Atenolol and Bisoprolol are the most common in this class, these medications usually prescribed once or twice a day.
o If it is prescribed once a day you may take it with Iftar every day.
o If it is prescribed twice a day and:
§ you live in an area where there is at least 8 hours before iftar and suhoor then it can be taken with these meals
§ you live in an area with less than 8 hours between iftar and suhoor then you need to discuss with your physician to adjust dose or replace with an extended-release version that is available for most of these medications.
v Clonidine:
o Clonidine is a special medication as you may have withdrawal symptoms (very high blood pressure) if not taken as prescribed which is usually 3 times a day, it is strongly suggested that it is switched to an extended-release skin patch during Ramdan (discuss with your physician)
One consideration for this is that the predawn meal may often be skipped by some people as it can be tempting to stay in bed instead of waking up. It is crucial to ensure this is not skipped when taking medication and to make sure you hydrate well.
When not to fast?
If blood pressures remain elevated or are in low range with symptoms of dizziness, headaches, blurry vision, or chest pain then medical attention may be warranted and it is advisable to break the fast.
Conclusion
Most medical studies have shown that patients with hypertension can complete their fast if they have no complications or other medical problems. If you have high blood pressure and wish to fast, fasting should not have a negative impact on your blood pressure balance. Please check with your doctor as each individual case could warrant different considerations.
References
Hypertension. World Health Organization. (whohttps://www.who.int/news-room/fact-sheets/detail/hypertension.int)
Whelton PK, Carey RM, Aronow WS, et al. 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA guideline for the prevention, detection, evaluation, and management of high blood pressure in adults: a report of the American College of Cardiology/American Heart Association Task Force on clinical practice guidelines [published correction appears in Hypertension. 2018; 71(6): e140–e144]. Hypertension. 2018;71(6):e13-e115.
Al‐Jafar R, Elliott P, Tsilidis KK, Dehghan A. London Ramadan Fasting Study (LORANS): rationale, design, and methods. medRxiv. 2021. doi: 10.1101/2021.07.14.21260518
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