It is that time of the year again. The temperature is creeping up into the forties, and the good mangoes are on the way. But also the ‘month of fasting’ is upon us. Soon the faithful will do what they do and for all practical purposes Pakistan will stop working for a month.

Not eating for most of the day is not a big deal if it is only about having breakfast a little earlier and dinner a little earlier and skipping lunch. Ordinary people will be doing just that and from a health point they will do just fine. Of course this group will not be reading this article.

Much medical research about eating less or fasting regularly shows a benefit to general health. As a matter of fact the only thing that is proven to prolong life is eating less. Many ‘devout’ physicians will mention this fact often to support the idea and the usefulness of fasting and they will be right.

The problem is the large number of people that sadly make a mockery of the very concept of fasting. They consume a full day’s worth of calories in the early morning and then another equal amount when they break their fast and perhaps even a bit more when they have dinner. It is this group that often ends up with medical problems during the month of fasting.

Many people overeat regularly and become overweight. That is a serious medical problem by itself. My concern today is about people who overeat occasionally. You might call them binge eaters. The problem with binge eating is that too much food for those not used to it is a stress for the body including the heart.

Overeating of the sort done during the month of fasting is almost always of food with a high fat content especially fried food. Before a long fast, eating food with a relatively high fat content helps in suppressing hunger since fat prevents the stomach from emptying quickly.

Unfortunately by keeping the stomach full for longer periods of time, there is tendency for the stomach contents containing acid to leak back into the food pipe (oesophagus). This produces irritation of lining of the food pipe causing heart burn. Heartburn is easily treated with medicines.

Sometimes heartburn is really from the heart and a heavy meal can initiate a heart attack. If the lower part of the heart is involved, pain from the heart can be felt as if it is heartburn. If heartburn does not go away with a glass of milk or anti-acid medicines then a trip to the hospital is warranted to make sure that the heart is fine.

Also people with known gall bladder problems (gall stones) should be careful with high fat content food being eaten frequently. Any and every high fat content meal can initiate a gall bladder attack. And a gallbladder attack is a serious problem that might require surgery.

Overeating in the early morning is conducive to a long late morning nap. During my years in Mayo Hospital most of my junior doctors who fasted were usually late to work. When I complained about this unprofessional behaviour, I was informed that a long nap after pre-fast eating and morning prayers was an intrinsic part of the fasting requirements. I never tried to find the truth about this claim.

Now then to more important and the relatively worrisome aspects of fasting. People with high blood sugar (diabetes) that take insulin injections to control their blood sugar need to be careful during fasting. They should consult with their physicians and retime their insulin injections according to the times they eat before and after fasting. Most diabetics can safely fast if they are careful.

The problem with fasting is not food but water or rather fluids. The major medical danger during fasting is from dehydration (lack of body water) especially in hot weather like we will be having over the next few months. People with high blood pressure that take ‘water pills’ that make them lose extra water should seek medical advice before fasting.

Older persons and those that work outside in the sun are particularly vulnerable to dehydration. If the body loses too much water then many bad things can happen. Most common and the most dangerous is that the blood pressure will go down causing the person to faint or get dizzy and fall down. There is no real solution for this problem except that during fasting if the person starts feeling extremely thirsty and light headed or dizzy they should seriously consider breaking the fast.

The body absorbs all the water that is consumed from the stomach and the intestines and once the water enters the blood stream it will be used up for normal body functions as needed. Drinking a lot of water in the early morning does not help since the water will be immediately absorbed and used up or removed from the body.

There are many strategies that have been advocated for decreasing the chance of becoming dehydrated during the fast. Some that work somewhat are to drink fluids that are not quickly absorbed and therefore stay around longer in the intestines. Most fluids that have some fat and protein content will serve such a purpose. Diluted milk, diluted yogurt, certain soups (nihari!), watery fruits are all going to hang around longer and give up their water slowly so that more water stays in the body for longer periods of time.

However, it is important to emphasise that those performing manual labour in the heat will tend to lose water in spite of any strategy. The same is true of professional athletes especially if they play in the sun and in the heat. Professional athletes cannot perform at peak efficiency if they are fasting and especially if they do not consume adequate amount of fluids.

What I said about athletes is undeniable and anybody that says otherwise is incorrect. In my opinion professional athletes have to make a choice between fasting and playing. Perhaps an appropriate ‘fatwa’ from the appropriate religious authorities might be in order.

There is one aspect of the month of fasting that does need to be made less strict. People that are not fasting or are too old, too young or too sick to fast should have public access to food and especially to water.

In recent years there were many deaths during the month of fasting that could be attributed to the fact that drinking water is not available to ordinary people especially to labourers working in public spaces. Clearly when the temperature hits the high forties, people working in the open under the sun may need water just to be able not just to keep working but to survive.

In a previous article on this issue I had suggested that the mosques all over our cities should take the lead in this matter and provide drinking water to the public during the fasting period.

And no, drinking or eating in front of those that are fasting is not an insult to them but a test of the strength of their resolve.

The author served as professor and chairman, department of cardiac surgery, King Edward Medical University.