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Ramadan and Healthy Eating – how primary care dietitians can support fasting patients

Author: Saman Shaikh, RD, MSc., CDE Sharbot Lake Family Health Team

The month of Ramadan is upon us, and some primary care dietitians may be called on to support patients during this time. Ramadan is a time of fasting, worship, introspection, and community for Muslims. It is the holiest time of year, and its observance is very important for Muslims. Following the lunar calendar and usually marked by the sighting of the moon, it is 29 or 30 days in length. In 2021, Ramadan is expected to start on April 13th and end on May 12th.

During Ramadan, Muslims abstain from eating and drinking (yes, even water!) from sunup to sundown every day. The observation of Ramadan is mandatory for all who are able to fast. Those who are exempt are children, the elderly, people who are ill, people with diabetes, people who are traveling, and menstruating, pregnant and breastfeeding women.

The daily fast is preceded by a morning meal, known as suhoor, before the sun comes up, in which people eat to fuel up for the day ahead. The suhoor meal can vary: some people have something light, like cereal, fruit, yogurt, or eggs. Some have a large meal heavy in carbohydrates and protein in effort to sustain themselves as long as they can during the day – typically some combination of bread, and meat, dairy and fruit. Some people may actually skip suhoor altogether, particularly if they don’t like waking up so early to eat – though this is not recommended.

At sundown, Muslims break their fast with a meal called iftar, typically starting with some fresh dates and a beverage, followed by their full meal.

As mentioned earlier, Ramadan is also a time of community and connection. Mosques and organizations host iftar dinners for community members. Families host lively iftar parties for friends and family. Ramadan is just as much a social event as it is a spiritual one. Of course, it has not been possible to meet socially since the Covid-19 pandemic hit in 2020, but people have found other ways of connecting, such as virtual iftar dinners.

To support people with healthy eating during Ramadan, primary care dietitians can encourage a balanced diet during suhoor and iftar, including high fibre and low glycemic index grains and starches, healthy proteins and fats, and a variety of fruits and vegetables. Vegetables may take a backseat for some people because of their low caloric density during this month, so dietitians should encourage patients to include vegetables at their suhoor and iftar meals. Adequate hydration should also be emphasized during pre- and post-fasting hours. Advise patients to limit high sugar foods and drinks with empty calories.

A healthy, sustainable suhoor could include:

 -Whole grains, such as breads, cereals, oats, barley etc

-Fruits and vegetables, including ones with high water content for hydration, such as cucumbers, oranges, watermelon etc, and those high in fibre such as okra, eggplant, berries etc

-Protein foods, such as lean meats and poultry, fish, beans, eggs, Greek yogurt etc

-Healthy fats, such as avocadoes, olive oil, nut butters etc

-Beverages, such as milk, tea, and water

After a full day of fasting, iftar can turn into a bit of a feast – people may make extravagant foods in large quantities in anticipation of the meal, and then overeat because they’re so hungry. Iftar also tends to include a lot of deep-fried foods – samosas, pakoras etc.

Similarly to suhoor, a healthy iftar should also include a balance and variety of foods as well. Encourage people to limit their intake of fried foods during this time. Also, one strategy to try and curb overeating at iftar is stepping away for a few minutes for evening prayers if possible after breaking their fast with dates and a drink, and then coming back to have their full meal. The delay may help control the speed and quantity of the meal.

The end of Ramadan is marked by Eid-ul-Fitr (or Eid for short), the day after the last fast, and it is a holiday full of joy and celebration. People congregate for prayers, give to charity, and get dressed up in their finest clothes and visit each other for lively gatherings filled with comradery, fun, gifts, and food.

The Covid-19 pandemic has made most of this impossible in the last year, but food is the one constant. Recognizing that it is okay to indulge occasionally, especially on special occasions, dietitians can encourage patients to practice moderation while eating on Eid day and eat mindfully while paying attention to their senses and hunger cues.

Practice tips:

-Don’t assume everyone eats the same foods or follows the same traditions. There are almost 2 billion Muslims living in every corner of the world, with different cultures and traditions, and practicing in many different sects of Islam. While the basics are the same, everyone does things a little differently. If you have the opportunity, do your research before counselling a patient, and you’re not sure of something, ask.

-Some people who are not obligated to fast, such as those who are pregnant, breastfeeding, or living with diabetes, may choose to fast anyway. While it’s true that fasting is exempt for these people, religious leaders do say that those who can fast, should. If a person is otherwise well and feel they are able to fast, don’t try to dissuade them from fasting. As primary care dietitians, we should discuss the topic with our patients, including acknowledging their desire to fast, understanding how important it may be to them, and informing them of the risks and benefits of fasting for them. If they have made an informed decision to fast, we should practice patient-centered care by trying to support them to the best of our capacity.  

If it is medically clear that someone should not be fasting, they should be advised not to fast. Examples of someone who should not be fasting are:

-an underweight patient in early pregnancy, or a pregnant patient who has not gained adequate weight during pregnancy.

-an exclusively breastfeeding mother with supply concerns,

-a patient with poorly controlled diabetes with frequent and severe hypoglycemia episodes

Did you know?

-Contrary to what you might think, some people may not lose weight during Ramadan – in fact, some end up gaining it.

-Ramadan doesn’t start at the same time every year. Since the Islamic calendar follows the lunar calendar, which is 11 days shorter of the Gregorian calendar, Ramadan moves earlier and earlier every year. In the long summer months, fasting days can be up to 18-19 hours long depending on geographical location. In short winter days, fasting can be 7-8 hours long.

Additional resources:

The Academy of Nutrition and Dietetics: https://www.eatright.org/health/lifestyle/culture-and-traditions/ramadan–the-practice-of-fasting

Shahzadi Devje: https://shahzadidevje.com/the-ultimate-guide-to-healthy-eating-during-ramadan/

Nutrition by Nazima: https://thehealthymuslims.com/ramadan/

Dietitians of Canada Practice Blog: https://www.dietitians.ca/About/Blog/Fasting-during-Ramadan-What-dietitians-need-to-kno

Diabetes Canada Clinical Practice Guidelines – Ramadan: https://guidelines.diabetes.ca/healthcareprovidertools/ramadan-and-diabetes IDF Ramadan guidelines: https://idf.org/our-activities/education/diabetes-and-ramadan.html

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