Ramadan

The Crescent Moon rising at sunset, marking the start of the month of Ramadan

The month of Ramadan begins tomorrow, July 9, and lasts until August 7.  As many of this blog’s readers will know, observant Muslims will fast from dawn until sunset:  no food, no liquids…..no sports drinks or power bars.  The questions of ‘carb loading’ or ‘gluten free’, (‘should i drink some chocolate milk after my workout?‘) can all be put on the table until the evening.  The diet is one of pure abstinence, morning until night.

Muslim athletes are not unique in observing a fast: Catholic Christians will consume much less than usual if observing the prescribed tenets of Lent on Ash Wednesday and Good Friday, and Jewish athletes will go a full 24 hours consuming nothing on Yom Kippur: friends have told me they will be loath to brush their teeth or even shower, lest anything whatsoever pass into their mouths on that, the holiest day in the Jewish calendar.

And, of course, there are athletes who experiment with fasts, juices and cleanses that have nothing to do with religious observance (I’ve tried the “Master Cleanse” myself once).

What may be unique, however, to Islam  is the duration of the practice:  a full 30 days, where an observant Muslim will forego all food and drink from dawn (Sahur) to dusk (Iftar).

I admire the discipline the act of fasting requires.  As a sports medicine clinician, I have often wondered how athletes observing such fasts might be impacted.  Of course, I am  not alone in this, as the subject of the Ramadan fast and its effect on athletes was, for instance, a subject of considerable interest in the 2012 London Olympics, which took place during Ramadan.  The effects of Ramadan on sports performance have even been discussed in this blog in a 2011 post.  And now  the most recent issue of the CJSM, which rolls out today, highlights a study looking at this very practice of fasting and its impact on footballers:  “Does Ramadan Affect the Risk of Injury in Professional Football.”

Abdullah Koni, a Qatari footballer, with the AFC CHampions League trophy

The authors of this study looked at players in the professional first division of football in Qatar:  the Qatar Stars League.  They prospectively followed 527 players (462 Muslim and 65 non-Muslim) from 2008 to 2011, gathering data on injury rates in practice and matches throughout the year, in order to assess the potential impact of Ramadan on injury incidence.  Their research hypothesis was that injury incidence would increase during the month of Ramadan.

The authors note that despite other studies looking at the effect of Ramadan on athletic performance, theirs is the first looking at the fast’s effects on injury risk.

Among the many things I learned reading this study:  because the Islamic calendar is a Lunar calendar, the first day of Ramadan occurs 11 days earlier each subsequent year.  Ramadan will, consequently, occur during different times of the year in our Western, Gregorian calendar over a 33 year cycle.  That is, Ramadan will affect Muslim players this coming football World Cup 2014 in Brazil as it did athletes in the London Olympics,  but by the time the 2016 Olympics occurs in Rio, Ramadan will have already ended before the Opening Ceremonies; and the fast will not have an impact again for the next several Olympiads and World Cups.

I also learned that in Muslim countries, football matches and training will not occur between sunrise and sunset during Ramadan, and in fact most clubs will wait 2 to 3 hours after sunset before starting a fixture to allow athletes sufficient time to eat and rehydrate.

The injury rate data were very interesting.  Injury incidence was calculated as a ratio of the number of injuries per hour of exposure and expressed as a rate per 1000 hours.  The authors used a ‘Generalized Estimating Equation (GEE)’  to calculate the probability of injury for the different Arabic months of the year and to assess the possible variance in injury rates between Muslims and non-Muslims.

The authors found that there were no significant differences in total, game, and practice injury rates for all players when comparing Ramadan and the other months of the year.  In other words, the data did not support their research hypothesis.

Conversely, they found that non-Muslim footballers had significantly higher injury rates than Muslim footballers both during Ramadan (8.5 vs. 4.0 injuries, per 1000 hours; p = 0.009) and non-Ramadan months (6.6 vs. 4.9 injuries, per 1000 hours; p = 0.004). Though at higher risk for injury throughout the year, non-Muslim players had a decidedly higher injury risk during Ramadan: a 3.7 odds ratio (95% CI 1.7 – 7.9) compared with Muslim players.

Why might this be?  In their Discussion section, the authors suggest (as an explanation of the stable injury rates observed over the entire year) that the accommodations clubs make during Ramadan (e.g. holding practices at times when players may be fueled and hydrated) may be working.  They also speculate that the rigors of Ramadan might lead to slightly less rigorous training sessions.  They tracked hours of practice, and found no differences in practice duration in or out of Ramadan, but they allowed they did not attempt to assess practice intensity.

As for the intriguing and statistically significant finding that non-Muslim athletes in the Qatari league had higher injury rates across the whole year–and rates of injury that were especially steep during Ramadan–the authors offered several potential explanations, all of which would suggest avenues for further research.

I encourage you to check out the new issue of the journal and the many interesting studies it contains in addition to this one on the effects of Ramadan. Or, check out other studies published in CJSM on the subject of Ramandan.  For now, on the eve of Ramadan, I will leave you with a couple of other links I think you might find interesting:

1) As the CJSM editor responsible for our twitter and Facebook feeds, I’m a fan of social media.  Check out this intriguing blog  post on efforts to promote physical activity in arabic speaking countries using social media.

2) Likwise, I’m a fan of apps that enhance the practice of clinical sports medicine.  Apps can be powerful and seemingly ubiquitous tools.  Ramadan?  Yep,  there’s an app for that!

In all seriousness, to my friends and readers who will  be observing the fast, Ramadan Kareem.  See you again soon on these pages.