Issue 51 July 2013

The E - Bulletin is a service provided from the in-house team of physicians (Specialists, GPs & the In-house Training Center)
at the CEDARS Jebel Ali International Hospital in order to raise awareness about health issues.

Nutrition during Ramadan

Ramadan is a holy month in Islam and Muslims observe fast-
ing from dawn to sunset. Ramadan word itself signifies the
amount of heat and dryness, which indirectly signifies the
increase of fluid and mineral requirement. Those who are ill,
travelling long distance, pregnant and nursing women, eld-
erly with chronic illness are exempted from fasting. However
many people fast during Ramadan irrespective of their health
condition. Coping with the nutrient needs becomes very
essential especially for these vulnerable section. A well
balanced diet will minimise the negative consequence of
fasting.
Ramadan fasting is intermittent lasting from 12 - 20 hours
followed by food intake and again fasting for a period of
thirty days. The main source of energy during fasting is the
breakdown of glycogen stores in liver and muscle and there Ramadan means scorching heat or dryness.

will be some amount of fat loss and muscle tissue breakdown. There is a significant loss of fluid and electrolytes (sodium,
potassium, chloride, bicarbonate, magnesium, calcium). Glycogen stores can be replenished once the food is consumed.
The main concern when fasting is the fluid electrolyte balance. As this is the period of peak summer and the fluid require-
ment is generally high it is necessary to drink enough water before and after fast to prevent dehydration.
.

Ramadan fasting does not lead to malnutrition since there is no restriction on type and amount of food intake before
dawn and after sunset. However factors such as unbalanced food diet, less intake, presence of any acute or chronic diseases
can lead to under-nutrition. Increased intake of fatty food, refined foods, sweets, junk food can lead to over-nutrition. Thus
it becomes very important to choose right food and right quantity to stay healthy.

Things to remember when fasting

Sufficient fluid intake
Drink a minimum of 8 glasses of water. Sufficient fluid intake is necessary to flush out the toxins, relieve the kidneys of the
burden of concentrating the urine to maintain blood homoeostasis as well as to prevent dehydration. Fluids can be in the form
of soups, juices or plain water.

Conserve body water

During the day stay in cool areas and limit physical activity to prevent excess fluid loss from the body.

CEDARS - Jebel Ali International Hospital, Dubai, UAE. Tel: 04-881-4000 Fax: 04-881-4001

CEDARS - Jebel Ali International Hospital is a full-fledged multi-specialty hospital offering services ranging from Pediatrics to Occupational Health, Laparoscopic Surge ry to
Internal Medicine. The Hospital is equipped with ICU for medical and surgical emergencies, with two major and one minor opera tion theatres and runs fully equipped Laboratory and
Radiology departments. CEDARS Jebel Ali International Hospital is accredited by TUV and JCI and located next to JAFZA Gate 2.
Page 2 Nutrition during Ramadan

Things to remember cont...

Do not overeat
Do not overeat as body's regulatory mechanism reduce the metabolic rate and ensure efficient
utilization of the body's energy reserve in times of hunger. Eating more will just add on to the
calories leading to weight gain. Have balanced, nutrient rich meals to replenish the recom-
mended allowances of protein, vitamins and minerals.
Go for low fat
Use low fat/skimmed milk & yoghurt, low fat cheese, lean meat.
Have balanced meal
Diet after fast should not be different from our normal routine diet. Make sure the meals con-
tain complex carbohydrates such as whole grains and whole grain bread, meat (lean meat),
beans, fruits and vegetables.
Avoid excess consumption of sweets and refined products
Refined products and sweets get digested very quickly in comparison to complex carbohy-
drates (whole grains and cereals) as they are digested slowly. Thus complex carbohydrates
are a better choice as there is constant supply of energy for a longer time and gives a feeling
of satiety.
Balanced calorie intake
Avoid unnecessary calorie consumption in the form of sweetened beverages, carbonated bev-
erages instead go for healthy choices like water, fruit juice with pulp, soups (without cream).
Do not eat too many nuts as they can add on to your caloric consumption and fat intake.
Say No to fried
Avoid fried and fatty food as it can cause heart burn or indigestion.
Rest
Schedule your sleeping hours as enough rest is also important.
Stay fit
Engage in light exercise like walk or stretching exercise. Ideal time to exercise is early in the
morning, before fast or in the evening after fast. Never exercise when fasting as it makes you
loose excess body water and exercising in starving state will lead to muscle tissue breakdown.

Diet management of chronic illnesses

Pregnant, lactating, diabetics and those with chronic disease should consult their physician, to
know whether it is safe to fast and consult dietician for diet and meal management.
Every individual is the judge of his or her own health - eat balanced meals, drink
enough water, stay fit, as health is a best gift and blessing one can get.

Diabetes
Diabetic patients who need to fast need an assessment and education before Ramadan to
increase the awareness of risk of fasting.
Risk associated with fasting are:
Hypoglycemia - low sugar levels due to decreased food intake
Hyperglycemia - increased sugar levels, due to insulin deficiency prolonged fast may
increase glycogen (glucose store) breakdown and reduced uptake by cells and clearance
leading to hyperglycemia
Diabetic ketoacidosis - increase in byproduct of excessive fat breakdown due to reduction
insulin/medication intake during Ramadan
Dehydration - limited fluid intake can cause dehydration
Thrombosis - decrease in endogenous anti-coagulants and increase blood viscosity
secondary to dehydration may enhance the risk of thrombosis.

CEDARS - Jebel Ali International Hospital, Dubai, UAE. Tel: 04-881-4000 Fax: 04-881-4001

CEDARS - Jebel Ali International Hospital is a full-fledged multi-specialty hospital offering services ranging from Pediatrics to Occupational Health, Laparoscopic Surge ry to
Internal Medicine. The Hospital is equipped with ICU for medical and surgical emergencies, with two major and one minor opera tion theatres and runs fully equipped Laboratory and
Radiology departments. CEDARS Jebel Ali International Hospital is accredited by TUV and JCI and located next to JAFZA Gate 2.
Page 3 Nutrition during Ramadan

Diet management cont...

Diet plays an important role in management of diabetes and the major dietary changes
include small frequent feeding with proper distribution of carbohydrates (wheat, rice) and pro-
tein (milk, fish, egg, meat, poultry, beans) and fat (oil).
People falling in moderate and low risk can fast under the supervision of medical team and
with the physician consent.
SELF ANALYSIS
At which risk do you come under?
High risk
Those with severe and recurrent episodes of hypoglycemia
poor diabetes control
Those with ketoacidosis (complication of diabetes involving excess fat breakdown and
increase in ketone bodies which is dangerous to health)
Pregnant women
Those who perform intense physical labour
Those with macrovascular complications, renal disease with dialysis, uncontrolled epilepsy
Moderate risk
Well controlled but on short acting insulin
Low risk
Well controlled treated with diet alone and mono therapy, with one medication who are
otherwise healthy
Diabetics who are considered safe to fast by physician assessment should follow the below
mentioned meal plan and dietary advice;
A healthy balanced diet
Slow energy releasing food (whole grains and cereals, like whole wheat bread, brown rice)
should be taken before and after fast whereas foods high in saturated fat should be minimised.
Use small amount of mono-unsaturated oil (olive oil) in cooking.
Consume high fibre rich food like vegetables, salad, whole grains and cereals.
Regular light exercise is safe for type 2 diabetics, rigorous exercise is not recommended.
Monitor glucose level regularly if possible everyday (with the help of glucometer)
When patient feels the symptoms of hypoglycaemia, and dehydration like dizziness, weak-
ness in the limbs, sweating stop the fast immediately.
Check with your physician for change of dosage of medications and timings.
After Ramadan follow up of HbA1c, body weight, blood pressure and lipid profile as well as
readjustment of medications becomes essential.
Renal Disease
Those with stable CKD and not on dialysis can fast but under close medical supervision with
strict attention to fluid intake daily activities and adjustment of medications with special atten-
tion for the management of diabetic CKD patients as diabetes is a leading cause of chronic
kidney disease. It is unsafe for persons on dialysis to fast, they should maintain their normal
food and fluid intake and continue taking prescribed medicine and undergo dialysis as planned.
Chronic heart disease
Those with controlled hypertension with no other coexisting cardiovascular disease can fast.
Fasting is unsafe for those with coronary artery disease with uncontrolled hypertension
Pregnant & lactating women
It is unsafe and not advisable for pregnant and lactating women to fast. However those with-
out any other complications and by physician consent can fast, but make sure that recom-
mended nutrients is consumed in non-fasting period.
Geriatrics or elderly
It is safe to fast for persons aged over 65 years provided they are in good health without any
diseases. Have balanced meals before and after the fast. Ensure sufficient water is taken.

CEDARS - Jebel Ali International Hospital, Dubai, UAE. Tel: 04-881-4000 Fax: 04-881-4001

CEDARS - Jebel Ali International Hospital is a full-fledged multi-specialty hospital offering services ranging from Pediatrics to Occupational Health, Laparoscopic Surge ry to
Internal Medicine. The Hospital is equipped with ICU for medical and surgical emergencies, with two major and one minor opera tion theatres and runs fully equipped Laboratory and
Radiology departments. CEDARS Jebel Ali International Hospital is accredited by TUV and JCI and located next to JAFZA Gate 2.
Page 4 Nutrition during Ramadan

Sports and Ramadan

Athletes should consume similar amount of food and fluids as per non fasting periods.
The suhoor meals should be had as latest as possible.
Consume low glycemic index food (those food which release glucose gradually) such as
whole grain cereals, fiber rich food. this helps to provide energy for longer period of time.
Exercise / training should be done preferably after breaking fast. have light meals, then
do the training followed by a proper dinner.
Fluid intake is same as per the daily requirement of the individual irrespective of fasting.
e.g., if daily fluid consumption is 2.5 to 3 litres per day then he/she should have same
amount of water between iftar and suhoor.

Sample Suhoor
menu Lentil soup
Ful medames with arabic bread
(whole wheat)
Grilled humour/salmon,
* do not a
d
1/2 tsp p d excess sugar,1 Salad with lemon and olive oil
er servin dressing
g is idea
l Fruit

Iftar
(Breaking the fast)
Fruit juice or date milk shake
with dates/dried apricots/figs or fresh fruit

Iftar dinner
Cucumber / pumpkin chilled Soup
Grilled chicken and vegetable pilaf
Toubouleh
Yoghurt salad
Fruit
*Also include the following low calorie nutritious drink
Green tea
Lemon juice
Low fat laban with finely chopped cilantro and ginger
(low fat, less salt)
Honeydew mint juice (blend honeydew melon chunks
with few mint leaves)

Medical Consultant for July 2013

Deepa D. Almeida is DHA certified nutritionist at CEDARS Jebel Ali International where she plans food
and nutrition programs to achieve the goals set by the physician for each patient and supervise the
preparation and serving of meals to patients. She is also in-charge of the hospitals food services
through its cafeteria.
She has previously worked as Nutritionist at Affinity International, Bangalore, India where she took
charge of nutritional assessment of individuals based on anthropometry, biochemical parameters and
other clinical indicators, prescribed diet, counseling.

She has undergone training and internship in clinical nutrition at St. Johns Medical College Hospital,
Deepa D. Almeida Bangalore, St. Marthas Hospital Bangalore, Sagar Apollo Hospital, Bangalore, Roti Ghar, Sri Jayadeva
Nutritionist Institute of Cardiology, Bangalore. She has also undergone industrial training in food and beverage
service and production at Le Meridian hotel, Bangalore and Atria Hotel, Bangalore.

Deepa speaks English, Hindi, Kannada and Konkani.

CEDARS - Jebel Ali International Hospital, Dubai, UAE. Tel: 04-881-4000 Fax: 04-881-4001

CEDARS - Jebel Ali International Hospital is a full-fledged multi-specialty hospital offering services ranging from Pediatrics to Occupational Health, Laparoscopic Surge ry to
Internal Medicine. The Hospital is equipped with ICU for medical and surgical emergencies, with two major and one minor opera tion theatres and runs fully equipped Laboratory and
Radiology departments. CEDARS Jebel Ali International Hospital is accredited by TUV and JCI and located next to JAFZA Gate 2.