Protect athletes' health and promote inclusivity during the imminent Ramadan, says BJSM article

Ramadan is due to begin in the UK on 2 April and end on 1 May, with the precise timings depending on various factors. Many athletes, like other Muslims who fast from dawn to sunset during Ramadan, report spending fewer hours overall sleeping as they fit in pre- and post-fast meals (suhoor and iftar), social activities and night-time prayers, the BJSM article points out.

‘Medical teams can promote inclusivity by implementing safety criteria to optimise performance and support athletes who train and compete during Ramadan,’ Dr Ahmed and colleagues note.

Some key considerations

• the effects of fasting are linked to the individual, the type of sport and the environment
• decisions should be informed by assessing the risk of adverse events – such as dehydration and heat-related illness in endurance events in warm climates
• habitual routines might be modified to include training in the evening, when it should be cooler, for example, or at night in non-fasting periods
• some options might be hard to implement in team sports or in countries where fasting athletes are in a minority
• athletes might delay fasting on competition days or make up fasting requirements in the off-season after discussions with a religious scholar (counsel)

The authors suggest the that some studies have reported that fasting during Ramadan had ‘clear negative effects’ on athletes’ performance in various exercise tests, while others found it had little or no impact. ‘Importantly, the available evidence suggests that high-level athletes can maintain performance during Ramadan if physical training, food and fluid intake, and sleep are appropriate and well controlled.’

Training just before sunset or during the dark hours allows nutrition interventions (such as boosting intakes of protein, carbohydrate, water and sodium) to be given afterwards. Such interventions ‘maximise adaptations to the training stimulus, promote recovery and potentially reduce exercise-induced muscle damage,’ the article suggests.

Some clinicians have advised giving athletes low-glycaemic-index foods in suhoor (pre-fast) meals but studies showed this had little effect on subsequent aerobic performance. Buccal (mouth) rinses with carbohydrate-containing drinks may be beneficial in some circumstances but carry a small risk of people inadvertently swallowing fluid or for small quantities of carbohydrate or water to remain in the mouth afterwards.

Athletes can consider daytime napping to ensure 'adequate sleep volume' throughout Ramadan, Dr Ahmed and colleagues suggest.

Greater awareness among sports clinicians and sports administrators of athletes’ fasting practices can help to promote inclusivity and protect athlete health [Irfan Ahmed et al.]

Conclusion

The authors add: ‘Greater awareness among sports clinicians and sports administrators of athletes’ fasting practices can help to promote inclusivity and protect athlete health. This can involve medical advice on when it is safe to fast, as well as input from nutrition, conditioning and coaching staff.

‘The latter are encouraged to develop training and competition strategies to help athletes to continue to perform at the highest level, while respecting their religious or cultural wishes to fast when training and/or competing.’

Factfile

• there are roughly two billion Muslims worldwide (one quarter of the population), making up the second largest religious community
• though Ramadan is widely practised throughout the world, few high-quality studies offer specific recommendations on maintaining elite athletes’ performance levels
• guidelines cover aspects of athletes' welfare, adaptations to training and competition strategies, but are largely based on expert opinion
• specific exemptions from the obligation to fast are granted in cases of medical emergency, pregnancy and breast feeding (other medical exemptions may be considered case by case, depending on underlying medical conditions)

To access the article, titled Competing in the Ramadan fasted state: for spirituality, health and performance, visit: http://dx.doi.org/10.1136/bjsports-2021-105230