Generally, Muslims who suffer from gastritis and peptic ulcer disease (PUD) will have numerous questions regarding issues pertaining to their illness and religious obligations in Ramadan. Experience (and even existing literature) will tell them that fasting may lead to unwanted complications as increased acid levels in an empty stomach during Ramadan can aggravate gastritis and PUD.
Thus, at one end of the spectrum are those who force themselves to fast despite the risks, while on the other are patients who irresponsibly take advantage of the privileges granted by the religion for the sick – both of which are contrary to Islamic teachings, which promotes the middle path (the path of moderation).
Hence, the balancing act between religious obligations and the obligations towards one’s health could never be more important in these circumstances.
As a start, it would be useful to understand the natural history of the disease. Gastritis is inflammation of the lining of the stomach while PUD is the breach of the mucosal surface of the digestive tract from the imbalance between gastric acid secretion and the gastrointestinal tract protective mechanism.
Both have similar causes, with the commonest being infection by a bacteria known asHelicobacter pylori (H. pylori) which occupies the stomach wall.
Overuse of certain groups of painkillers such as non-steroidal anti-inflammatory drugs (ibuprofen, naproxen and aspirin), high dose steroids, heavy alcohol consumption and smoking can also contribute to the gastritis and PUD.
Emotional stress is no longer thought to be a cause of ulcers, but people who are experiencing emotional stress often report of increased symptoms of existing ulcers.
However, physical stress, (for example, severe burns) is different. It can increase the risk of ulcers, especially in the stomach.
In general, patients experience dyspepsia, which is a feeling of unease below the ribs (up to the chest) or may have previously suffered from complications like severe pain over the area and vomiting blood. It is also common to have acid reflux in association with these conditions.
Gastritis and PUD can be diagnosed via upper endoscopy (a thin, flexible fibre-optic instrument is passed through the mouth to the stomach and duodenum) and during the procedure a small biopsy can be taken from the lining of stomach wall to detect H. pylori.
Other non-invasive techniques to detect the presence of H. pylori include blood antibody test, urea breath test and stool antigen test.
Patients can take several simple steps to reduce the risks of complications of gastritis/PUD while fasting. The Prophet as a matter of fact has emphasised the virtues of suhur – the pre-dawn meal, which is either not practised (as people find it challenging to rise in the early hours of the morning) or not observed the way that the Prophet performs it.
A widespread habit among Muslims is sleeping straight away after suhur. This can result in acid reflux. Perhaps we should appreciate the virtue of another saying of the Prophet, “Delay the suhur but hasten the fast breaking.”
Another common practice for many Muslims is overeating during breaking fast, followed by smoking. This bad habit indeed paves the risk of triggering dyspepsia and acid reflux for gastritis/PUD patients.
Therefore, patients should be moderate when breaking their fast, eating in smaller portions, but more frequently. For instance, start off with dates and light food before giving it a rest after maghrib prayers, followed by the main meal prior to taraweeh prayers.
Another good practice is to stop eating three to four hours before going to bed to give the digestive system ample resting time. Hence, patients should consider minimising the guilty pleasures of the post-taraweeh prayer meal traditionally known as “moreh”.
In addition, try to reduce the consumption of hot, spicy and acidic-containing foods as they tend to irritate the digestive tract.
Caffeinated drinks like coffee, being a natural diuretic, stimulates the body to expel water via the bladder, which in turn leads to dehydration. Sweet drinks also make you pass a lot of urine and make you thirsty. So, the best alternative here is to vary your food intake throughout Ramadan to include all the essential nutrients such as carbohydrates, proteins, fat, vitamins, fibres etc.
In addition, drink lots of water to replenish the daily losses, which we unconsciously lose via breathing, sweating and going to the toilet. This could possibly amount to a staggering 2.5 litres a day!
Apart from lifestyle control, certain classes of medications may be used to manage gastritis and PUD. They include the antacids (e.g. gaviscon), proton pump inhibitors (e.g. omeprazole, esomeprazole, pantoprazole) and H2 antagonists (e.g. ranitidine).
Some medications like antacids can be obtained over the counter, but for the latter two, a doctor’s advice is required to tailor the dose and timing according to the patient’s needs.
For patients who are on these medications long term, you should also discuss with your doctor about any necessary changes, for example, splitting the dose to optimise the medication effect. Do not let fasting affect your compliance towards your medication.
My final point is to address some red flags that gastritis and peptic ulcer patients should be wary of. If you have persistent nausea and vomiting, pass blood in the vomit or pass black tarry stool and experience severe pain over your abdomen, please seek help urgently.
Relatives and acquaintances should also observe these patients for paleness in their complexity, especially at the face and palms, because this could be a sign of anaemia (from occult bleeding).
Recent changes in the patient’s weight and eating habits should also be alerted to their doctor as they may consider doing further investigations.
To conclude, I would like to re-iterate the importance of balancing religious obligations and obligations towards one’s health. Islam is not a religion that simply imposes strict laws to be followed without question; rather, it acknowledges the limitations of each individual by providing alternatives in accordance to their own abilities.
Four tips for Ramadan
Avoid
- Fried, fatty and acid-containing foods and fruits (e.g. citrus fruits like lemons, limes, grapefruits and oranges) along with tomato-based products (tomato is technically a fruit containing a lot of acid).
- Extra-spicy foods and tinned/processed foods, especially tomato-based products. Processed foods with a long-shelf life typically have a lot of chemicals, including preservatives, which could further exacerbate gastritis or PUD.
- Foods containing too much sugar and refined carbohydrates.
- Over-eating during breaking of fast and suhur and delaying breaking of fast.
- Caffeine-containing drinks like tea, coffee, sodas, etc. These make you pass more urine, taking with it valuable mineral salts that your body would need during the long day of fasting.
- Smoking is associated with gastritis and peptic ulcer disease. So, Ramadan is a brilliant opportunity to cut down on cigarettes. Smoking also slows the healing of existing ulcers and contributes to ulcer recurrence.
- Medications that can irritate the lining of the stomach.
Eat
- Carbohydrates or slow-digesting food at suhur so that the food lasts longer, making you less hungry as well as more energetic for the day.
- Dates are an excellent source of sugar, fibre, carbohydrates, potassium and magnesium.
- Almonds are rich in protein and fibre. Ground almonds and milk make a healthy drink.
- Bananas are a good source of carbohydrates, potassium and magnesium.
- Eat oven-grilled foods rather than fried and fatty foods.
- Eat in moderation and in smaller quantities, and break the fast early.
- Suhur in the way taught by the Prophet is virtuous both religiously and in terms of reducing the risks of complications.
- Don’t forget to take your prescribed medications during the break of fast or suhur.
Drink
- Drink water, non-acidic fruit juices and drinks containing potassium as much as possible between break of fast and bedtime so that your body may adjust fluid levels for the next day.
- Drink a full glass of fresh milk during suhur as this will help those with gastritis and PUD.
Watch
- Research shows that fasting can be associated with complications in gastritis and PUD patients, but the risks can be managed if appropriate precautions are taken.
- Research shows that stomach acidity levels peak at noon, so watch out for symptoms and complications after this time.
- Subtle changes that should be observed are pale complexions (especially in the inner eyelids and palms) and changes in weight and appetite.
- Islam does not force you to fast if you are unable to, so explore the alternatives that suit your abilities. You know yourself better than anyone else.
- Get your doctor’s advice before or during Ramadan if you have any concerns about your condition or medications.
Prof Madya Dr Raja Affendi Raja Ali is a consultant gastroenterologist.
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