“If I was fasting it would be for my eating disorder,” said Khanom, a 29-year-old Londoner. The religious duty that many Muslims find nourishing for the soul may, in his case, offer “permission…to fall back into my old ways and lose weight and not be judged for it because everyone the fact”.

A time of adoration, contemplation and joyful encounters with family and friends, Ramadan is also a month where food plays a central role, from the ritual fasting of the day to the festive iftar meals to break the fast.

For Muslims struggling with eating disorders, navigating these religious and social rituals can pose unique challenges. It’s a struggle that they and the specialists who treat them say is often largely invisible to society at large, which can sometimes make it all the more difficult.

“Understanding of eating disorders in general is minimal,” said Ghena Ismail, director of the eating disorders program at the American University of Beirut Medical Center in Lebanon. “People are just starting to appreciate mental illness.”

Fasting from sunrise to sunset during Ramadan, which began this year in early April, is a religious obligation, one of the five pillars or fundamental beliefs and practices of Islam. Faith allows for exceptions, however, such as for young children and sick adults.

The advice Ismail gives to Muslims with eating disorders depends on each individual’s stage of treatment. For those with severe symptoms, she recommends not fasting. She holds one-on-one discussions about the purpose of fasting and alternative ways to feel connected to the faith, such as reading the Quran and focusing on the charity element of Ramadan. Self-compassion is the key.

“I reframe this as part of their real duty to themselves and to the relationship with the Creator, that you cannot engage in any type of ritual to the detriment of your own health,” Ismail said.

“It becomes an opportunity to help them recognize their eating disorder as a clinical condition with medical, psychological and interpersonal consequences,” she continues.

As for Khanom, she faces potential triggers in the fasting and festive elements of Ramadan. She is recovering from developing anorexia as a teenager, which usually involves severe undernourishment and can be fatal if not treated in time, and bulimia, which involves the consumption of large amounts of food followed by a purge.

The ubiquitous conversations about food stress her out, and being invited to iftar without knowing what will be served can also be overwhelming since she prefers to plan her meals as a health measure.

“When I see a lot of food, I’m afraid I’ll be tempted to eat so much and start purging again,” she said. “It was a big, big achievement to stay away from that.”

Since Ramadan is also the only time of year when her family eats together, she fears it will put her under a microscope, as loved ones might scrutinize what’s on her plate or offer her more food.

This Ramadan, she approached it day by day. Some days she fasted; others it did not. Some evenings, she ate her iftar meal alone; others, with family.

In a personal triumph, Khanom found herself more at peace with her decisions: “It’s okay if I keep eating when other people aren’t eating, because I’m taking care of myself.”

Recently, Beat, a UK charity supporting people with eating disorders, hosted an Instagram chat about navigating Ramadan, in which Omara Naseem, a London-based psychologist who specializes in these conditions, reminded anyone who feels guilty for not fasting that medical exemptions are explicitly permitted by Islam.

Naseem, who has developed Ramadan guidelines for people with eating disorders, also advised them during the event to focus on activities that can help them relax and feel good, while remembering other ways to observe the holy month.

In a separate Instagram post, Beat offered tips for self-care during the Christian holiday of Easter, which can also cause anxiety due to the increased focus on changes in food and dietary routine.

“Any celebration, whether religious or not, that revolves around food can have its challenges,” said Edward Emond, assistant director of services at Beat. “We find a lot of people… approaching us for support here in preparing for these times.”

Dr. Rania Awaad, director of the Muslim Mental Health and Islamic Psychology Laboratory at Stanford University, said discussions of eating disorders and Ramadan fasting come up frequently in medical circles.

When clinicians turn to her for religiously and culturally sensitive advice, she tells them to take each case individually and consider factors such as a person’s stage of treatment and whether other conditions medical are involved.

“Don’t make a blanket statement,” Awaad said.

Halima Said, a Professional Clinical Counselor Associate in San Diego, recently decided to create “a safe space” for Muslims who cannot fast due to an eating disorder. Through an organization she co-founded, virtual support groups have formed that have drawn people from the United States and beyond, to Australia, Canada and England. From the original plan of one session every Sunday for the month, Said doubled that due to demand.

Participants found mutual support and bonded through common struggles such as anxiety over iftar meals and dealing with comments about their bodies from family members and misunderstandings about their illnesses.

“The last thing they would need pressure on is being ashamed of not fasting when they are sick,” Said said. “The eating disorder is a disease, and it’s a very manipulative disease.”

Associated Press religious coverage receives support through the AP’s collaboration with The Conversation US, with funding from Lilly Endowment Inc. The AP is solely responsible for this content.