Ramadan is a sacred lunar month that is observed by Muslims around the world through increased God consciousness and participation in acts of worship; including prayer (Salah), giving to charity (Sadaqah) and fasting (Sawm).
As we greet the sacred month, this article seeks to delve into some of the deeper meanings behind Ramadan fasting (Sawm) before going on to explore its relationship with holistic health and chronic systemic inflammation, a recognised precursor to many burdensome chronic diseases.1
Self Restraint and Mindfulness
“Oh you who believe. Fasting is prescribed on you, as it was prescribed on those before you, that perhaps you may develop taqwa (God consciousness)” Quran 2:183
A good place to start is with the concept of ‘Sawm’ and the intended spiritual and mindful benefits of Ramadan. Despite the fact that the act of intermittently fasting from food and water during daylight hours is what attracts the most attention, perhaps the first thing to clarify is that the Arabic word ‘Sawm’, is in fact incompletely translated as ‘fasting’. ‘Sawm’ is more accurately translated to ‘abstinence’ or ‘self-restraint’.
Beyond fasting from food and water, Sawm is to fast from harmful thoughts, sights and sounds, from sexual activity and recreational drugs. At its essence and by intention, Sawm is a deeply spiritual pursuit designed to allow the participant to confront the bodily discomforts and experiences that are normally dulled by the aforementioned worldly indulgences. (Think of it perhaps, as getting hungry to practice taking command over your ‘hangry’). Whilst weaning off from external stimulants and energy sources, a Muslim seeks to create the necessary space to discover their spiritual inclination and drive. Daily Sawm during Ramadan is akin to an intensive ‘boot camp’ to exercise the spirit, as well as the body and mind.
As such, Sawm can be viewed as a ‘conscious’ or ‘mindful’ activity. The unaddressed needs and wants of the body and mind will inevitably emerge when not contained. The exercise of fasting, much like the practice of meditation, is to confront, address and let go of the discomfort of our emerging desires. Whether driven by hunger, sexual arousal or blind rage, our unaccommodated addictions of thought and behaviour with inevitably emerge when we starve the body of what we typically pacify it with. Rather than blowing up and throwing gang signs at the maniac who cut us off in traffic, Sawm is to endure and allow any anger within us to pass, rather than project it. Of course, any Muslim will tell you that during the acute caffeine withdrawal of the first week of Ramadan, this is much easier said than done.
The reward, as is the case for all suffering that is successfully endured, is growth. To a participating Muslim, Sawm is first and foremost the squat rack of the spirit. This is not to negate the impressive benefits that intermittent fasting brings to our body health however. In the rest of this article, we will explore intermittent fasting during Ramadan and its impact on our metabolic health, with particular attention to systemic inflammation, a critical precursor to multiple chronic disease states.1
Intermittent Fasting
As we have previously discussed, to a participating Muslim, Ramadan is intended as a primarily spiritual intervention. However, it also has profound and well-studied effects on our bodies through the abstinence from food and drink during daylight hours.2 In 2022 this involves an intermittent fast which, depending on where in the world you live, lasts anywhere between 11 (Johannesburg, South Africa) and 17 hours (Reykjavic, Iceland).
The concept of intermittent fasting is not new. Many faith traditions including Jews, Christians and Muslims have observed variants of religious intermittent fasting for thousands of years.3 Whilst Ramadan has remained a constant for my entire life and one-and-a-half-thousand years before it, interest in the practice has only penetrated ‘mainstream’ medicine over the past 10-15 years. As a Muslim healthcare professional I have been particularly interested in tracking the shift in medical and societal perceptions towards fasting over this period.
Whilst working as a junior doctor, I recall once being challenged by one of my consultants as to the ‘ethics’ of ‘fasting on the job’, and to consider the ‘risk to patients’ after having suspiciously declined a slice of cake during a lunchtime meeting. (As a side note, many Muslims will assert that the sudden increase in tempting cakes and biscuits found in the workplace tea room is amongst the unquestionable miracles of Ramadan). Now, it is well established that practice of intermittent fasting typically assists with improved cognition and more focus and alertness when fasted.4 I suspect that I was a lot more switched on for the rest of my shift than I would have otherwise been if I had indulged in that sponge cake!
Recently, online support groups and blogs focused on intermittent fasting bustle with subscribers. The r/intermittentfasting subreddit is fast approaching a million subscribers, all sharing anecdotal tips, posting weight loss progress pictures and sharing success stories.
Alongside our ever-evolving societal perceptions, the academic evidence base has also been rapidly emerging to support the role of intermittent fasting.3 This table shows the explosion in publication interest since the early 2000’s, and the signs are that this interest is only growing.
Systemic inflammation and Metabolic Syndrome
“The son of Adam cannot fill a vessel worse than his stomach, as it is enough for him to take a few bites to straighten his back. If he cannot do it, then he may fill it with a third for his food, a third for his drink, and a third for his breath.” Prophet Muhammad PBUH
The role of intermittent fasting during Ramadan is increasingly investigated regarding its effect on reducing systemic inflammation.5 This is a closely linked to, and suggested precursor of multiple chronic disease states including metabolic syndrome, autoimmune and rheumatic musculoskeletal conditions.4,6
Fasting achieves this via a number of proposed mechanisms. At a biochemical level, intermittent fasting leads to the suppression of pro-inflammatory cytokine expression, with studies demonstrating significant reduction in c-reactive protein (CRP), tumour necrosis factor (TNF) alpha and interleukin (IL)-6 and IL-1β in healthy subjects after Ramadan fasting.7 A 2014 metanalysis of 30 studies also showed that fasting during Ramadan reduced body weight, total cholesterol and low-density lipoprotein cholesterol (LDLC).8 A further metanalysis of 85 studies of Ramadan fasting demonstrated significant reductions in key features of metabolic syndrome with reductions in waist circumference, fasting blood glucose, blood pressure and total tiglycerides.9
The Microbiome
Another possible mechanism in managing systemic inflammation is the impact that Ramadan fasting has on the gut microbiome. Imbalance in gut microbiota is linked to systemic inflammation and rheumatism.10. Ramadan intermittent fasting has been shown to correct imbalances in intestinal microbiota composition, with demonstrated increases in ‘healthy gut bacteria’ A. muciniphilia and B. fragilis after a month of fasting.5,11 Normalisation of oral and gut microbiome is shown to occur after treatment for rheumatoid arthritis.12
Bodyweight and body composition
Finally, Ramadan fasting may regulate systemic inflammation through its effect on weight loss, reduced waist circumference and improved body composition.9 These factors are also linked to reduced systemic inflammation.13 Studies show that there is a positive corelation between the extent of weight loss and the starting body mass index (BMI), suggesting that more overweight and obese patients have more potential benefit for weight loss from Ramadan fasting.14 A systematic review of 183 athletes also demonstrated reductions in BMI, body fat, and body fat percentage during Ramadan were associated with no change in lean mass, which points towards an improvement in over-all body composition.15
Conclusion
“Whoever doesn’t give up lies and acting on them, then God has no need for him to give up food and drink.” Prophet Muhammad PBUH
Whether due to a spiritual, lifestyle or health pursuit, intermittent fasting is here to stay. Many patients self-prescribe intermittent fasting to lose weight, improve their cognition and focus or simply to assist with meal planning around a busy lifestyle. From a medical perspective, doctors are increasingly prescribing intermittent fasting regimens to manage insulin resistance, diabetes, obesity and cardiovascular disease.4 Given the evidence of a correlation between intermittent fasting and improved chronic systemic inflammation, it is likely that the benefits are far more wide spread than we are yet aware.5
As a sport and exercise physician, I am keenly aware of this role fasting has in managing metabolic diseases, obesity and chronic inflammatory rheumatic and musculoskeletal condition such as rheumatoid arthritis, osteoarthritis and spondyloarthropathies.16 The implications for intermittent fasting however likely go far beyond this, with evidence emerging of benefit to cardiovascular17 and renal health18 as well as managing cancer risk.19
As an easily prescribed and relatively safe intervention, health practitioners are encouraged to reflect on the benefit of Ramadan fasting in their Muslim patient populations and to consider intermittent fasting as an intervention for their chronic disease patients. To the non-Muslim reader interested in trying it out, why not consider making the most out of the experience by fasting a few other organs (beyond just the stomach) and using it as a means to access your own spiritual strength.
Dr Mohammad Jomaa
Sport and Exercise Physician
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Those workplace cakes are test from Allah