Aminat Awogun, BPharm student

Ramadan is the ninth month of the Islamic calendar. During Ramadan, Muslims stay away from eating, drinking, smoking, and sexual activity, in addition to oral medications being prohibited, from sunrise to sunset. The fasting period can last about 10 to 19 hours per day depending on the region, after which they can engage in these activities until the next fast at dawn.

Fasting during the month of Ramadan is compulsory for sane and healthy Muslim adults. Besides abstinence from food, there is also a change in the sleep pattern with a prolonged restlessness during the night.

Many Muslims see the month of Ramadan as an opportunity to make healthy changes to their lifestyle and quit harmful choices, such as smoking.

Some individuals and situations have been exempted from fasting. These include: neonates, women during their menstrual period, travelers, elderly or frail patients, mentally disabled, breastfeeding women when fasting for long hours will cause discomfort for the baby and the mother, and people living with chronic and acute diseases.

Physiological Changes That Occur During Fasting

During fasting, the body enters a state of gluconeogenesis, which is a natural process in which the body generates glucose from non-carbohydrate substrates. Since no carbohydrate is coming in, the body makes use of the excess fat to produce energy and conserves this energy during fasting.

As the fasting period prolongs, the body observes a slow metabolism. At this point, there is a reduction in the heart rate and body temperature. Some changes also occur in the hormonal levels, such as a reduced production level of insulin and a rise in glucagon.

Pharmacists need to know the changes that occur in the body during fasting. This information will help them understand the patient medical needs during fasting and make proper adjustments in the treatment regimen where necessary.

Spiritual and religious beliefs are important social determinants that can affect a patient’s attitude toward treatment. With this, health care professionals need to have a basic understanding of these socio-determinants to deliver culturally relevant care.

Some patients may feel left out from this practice when they are not allowed to fast because of their medical conditions. For example, patients with chronic or acute medical conditions or patients whose medical condition may get worse from fasting are exempted.

Despite this exception, patients may choose to discontinue medications or alter treatment regimens against medical advice. This, of course, can lead to serious complications, such as hypoglycaemia, dehydration, irritation, and forgetfulness. This supports the idea that Ramadan may be a cause for non-compliance to medications.

Ramadan can also become complicated when patients have to take medications daily, as some medications are taken more than once per day, which may invalidate the fast.

Some routes of drug administration can also invalidate fasting. Although some non-oral medications are accepted during fasting, some Islamic scholars still debate the validity of drops, suppositories, and intramuscular administration.

How Pharmacists Can Assist Their Muslim Patients

It is easy for pharmacists to make an informed choice with their Muslim patients when they know the medication types, diseases, and routes of drug administration that may invalidate fasting.

Patients, together with their health care providers, can discuss these challenges with Islamic scholars, because knowing the patient's stand on some rulings can also help the health care provider to make informed choices.

Pharmacists need to consider patients who are willing to fast, as modifications can be made to the treatment regimen. For example, if a patient is to take a medication every 8 hours, the pharmacist may suggest another alternative that can be taken once per day. Further, if there are no alternatives, the pharmacist needs to communicate clearly to the patients when fasting could particularly put their health at risk.

Pharmacists should also discuss various options available to patients suffering from chronic conditions that require them to take medicines regularly.

In all, the health of the patient is more important than fasting. In patients with diabetes, fasting can be particularly challenging because it puts patients at risk of hypoglycemia. Patients with diabetes should therefore seek the advice of their health care providers before commencing their fast due to their chronic metabolic disorder. The disorder can place them at high risk for various complications if there are changes in the pattern of their food intake. Pharmacists should also monitor the patient’s insulin level before and after fasting.

Advising patients to consume enough water before and after fasting and limiting exposure to the sun and high temperatures are also important counseling points for pharmacists.

Before the start of Ramadan, it is recommended that pharmacists plan the management of medicines and health with their patients. Pharmacists can offer professional advice to the patient’s physician when there is a need for alteration in the medicine regimens.

It is important for patients to be advised not to make changes to their prescribed medications without consulting their pharmacist or physician.

1.Nadia Bukhari. How Pharmacists can support and advise patients during Ramadan. Pharmaceutical Journal. 03 June 2016.

2.Heba A., Al-Moujahed A. Muslim Patients in Ramadan: A review for primary care physicians. 2017. Avicenna Journal of Medicine. 7(3): 81-87.

3.Sanvictores T., Jarett C., Martin R. Physiology, Fasting. 2020. StatPearls.

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This information will help them understand the patient medical needs during fasting and make proper adjustments in the treatment regimen where necessary.

How Pharmacists Can Optimize Care for Muslim Patients During Ramadan

Over the past 2 decades, there has been an increase in the consumption of sugar worldwide, partly because of beverage marketing and growing urbanization.

 This lifestyle is deeply rooted in western countries. Data from the United States National Health and Nutrition Examination Survey showed that the intake of sugar in the US population surpassed the recommended calorie intake, with the average intake of men and women aged 18 years and older being 1.5 and 2.8 greater, respectively.

On average, half of the US population consumes sugary drinks on a given day, with data showing 1 in 4 people get at least 200 calories daily from sugary drinks.

 Consumption of sugary drinks regularly may be a major contributory factor to the epidemic of cancer, according to a study published by the 

According to the study, a sugary drink is more than 5% sugar, which includes sugar-sweetened beverages, soft drinks (carbonated or non-carbonated), fruit drinks, sports drinks, energy drinks, and 100% fruit juices. These beverages are the single most significant sources of calories in the United States.

The study assessed the correlation between the consumption of sugary drinks and artificially sweetened beverages, plus the risk of overall cancer, breast cancer, prostate cancer, and colorectal cancers.

The result of the study found that a 100 mL/day increase in the consumption of sugary drinks is associated with an 18% increased risk of overall cancer and 22% increased risk of breast cancer. Surprisingly, the consumption of 100% fruit juice, despite the natural and overall healthy image in the population, was also significantly associated with the risk of overall cancer. Although the sample study was large, an even larger-scale replication is still required, according to the study authors.

Possible risk factors for cancer, including sex, age, family history of cancer, smoking status, and physical activity level, were taken into consideration; however, the connection between sugary drinks and cancer remained the same.

Sugary drinks promote the accumulation of fats in the visceral area through changes in the adipokine secretion and cell signal pathways. The increased visceral deposit plays a role in the development of cancer, independent of the body weight.

In the study, obesity and weight gain were not the only driving pointers for the association between sugary drinks and cancer. High simple sugar consumption is not only associated with obesity, but is also linked to type 2 diabetes, and insulin resistance, which are positive risk factors for the development of cancer.

Although it is necessary to carefully interpret the study, the findings add to the evidence showing that a reduction in the consumption of sugary drinks decreases the risk of overall cancer. The research team found no correlation between sugary drinks and prostate or colon cancer because few people in the study developed these cancers, making the findings less definitive.

According to the study authors, another possible link between sugar and cancer is the high glycemic index. Several sugary drinks contain advanced glycation end products, which can impair the epithelial function in patients with or without diabetics.

The increase in glycemic index raises postprandial blood glucose, which in turn increases the risk of cancer by stimulating the synthesis of insulin-like growth factor. A high glycemic index is associated with hyperinsulinemia and type 2 diabetes, which are both risk factors for the development of breast cancer.

Furthermore, the research team observed high sugar contents served as the driving link between sugar and cancer, with daily intake of sugar from drinks largely associated with cancer. Sugary drinks with low sugar contents that were consumed in higher amounts were also positively associated with cancer.

In contrast, the research found no link between the risk of cancer and consumption of coffee, artificially sweetened beverages, diet soda, and unsweetened tea.

In addition, sugary drinks contain an additive, 4-methylimidazole, found in drinks that contain caramel coloring, or artificial sweeteners such as aspartame, which may also play a role in carcinogenesis.

Consuming sugar-sweetened beverages regularly is not healthy, as it is associated with diseases such as heart diseases, diabetes, and obesity. Interestingly, the metabolic alterations caused by the consumption of sugar has also been linked to the development of hepatocellular carcinoma.

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Natasha T., Li J., and Nancy P. Sugars in diet and risk of cancer in the NIH-AARP Diet and Health Study. 

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The American Journal of Clinical Nutrition

Eloi C., Bernard S., Elisa D., Mathilde T. 

. Sugary drink consumption and risk of cancer: results from NutriNet- Sante prospective cohort. BMJ, 2019;I2 408 DOI: 10. 1136/bmj.I2408

Consumption of sugary drinks regularly may be a major contributory factor to the epidemic of cancer, according to a study published by the British Medical Journal.