Highlights of the Year's Literature
Several themes were addressed in the year's harvest, excluding diabetes-related work,
as listed in [Table 1]. These will be discussed concisely below.
Table 1
Emerging themes from the literature review on health-related literature in 2021
|
1
|
Impact on patients with chronic diseases in general
|
|
2
|
Impact on various aspects of physiology and nutrition in healthy individuals
|
|
3
|
Ramadan's impact on welfare, competitiveness, and safety of athletes
|
|
4
|
Impact on management of hypothyroidism and adrenal insufficiency
|
|
5
|
Impact of COVID-19 on delivery of medical care during Ramadan
|
|
6
|
Cardiovascular outcomes and risk factors during RF
|
|
7
|
RF impact on renal function, physicians' decision-making and patients' perspectives
|
|
8
|
Gastrointestinal and hepatic function during Ramadan
|
|
9
|
Ramadan and maternal and fetal well-being.
|
|
10
|
Ramadan and neurological disorders
|
|
11
|
Changes in the eyes' structure and function
|
|
12
|
Ramadan's effects on rheumatological, hematological, and oncological conditions.
|
|
13
|
Care of post-bariatric and post-transplant patients during RF
|
|
14
|
RF and mental well-being
|
Abbreviations: COVID-19, coronavirus disease 2019; RF, Ramadan fasting.
General Considerations
The impact of RF on patients with chronic diseases and their experience during fasting
was investigated using face-to-face interviews with individuals with at least one
chronic disease.[3] Participants were first asked about RF, and those not fasting were asked only the
reason(s) and collected sociodemographic data. Fasting participants were enrolled
in the research interviews. The survey consisted of 19 questions designed to evaluate
the fasting behaviors, current chronic disease, and treatment status of individuals
who encountered complications during fasting and their sociodemographic data. There
were 253 participants with noninfectious diseases. About 63.2% of participants were
fasting during Ramadan, 20.6% had consulted a doctor before fasting, and 62.5% never
faced any symptoms. Many people with chronic diseases experience symptoms while fasting.
Impact of RF on Physiology and Nutrition
Five original research articles and five systematic reviews addressed the impact of
RF on various aspects of physiology and nutrition.
The original studies addressed various RF-related biological and behavioral changes.
The effect of RF on the metabolic profile, anthropometry, and serum leptin and adiponectin
concentrations was examined in 27 healthy males.[4] Reductions in body weight, fat mass, muscle mass, and waist circumference followed
the reductions in energy intake. Insulin sensitivity improved, and serum insulin concentration
and homeostatic model assessment of insulin resistance decreased significantly with
no significant change in fasting plasma glucose. A significant correlation between
the percentage changes in body weight and percentage changes in serum leptin concentration
was observed. Also, the effects of RF on resting energy expenditure (REE), body composition,
and nutritional status of 27 adults who fasted in 2019 were investigated.[5] REE was measured using indirect calorimetry, and 3-day food records evaluated dietary
energy and nutrient intakes before and after Ramadan (BR and AR). Body composition
and some metabolic parameters were analyzed simultaneously with REE measurements.
Bodyweight, body mass index (BMI), fat-free mass, and hydration status decreased in
males and females after the RF. REEs of the participants were decreased by 6.5% post-Ramadan.
The decrease in REE was greater in females than that in males. However, no significant
difference was found in sleep duration (h), physical activity levels, dietary energy,
nutrient intakes, and blood pressures (BP) of both sexes compared to baseline. Thus,
RF may lead to a decreased energy expenditure and a change in fat-free mass in healthy
individuals. Hydration is important to human health, as water is a critical nutrient
in many physiological processes. However, there is currently no clinical gold standard
for noninvasively assessing hydration status. A simple time of flight technique for
estimating permittivity was used to investigate microwave-based hydration assessment
using a population of volunteers.[6] Comparing the estimated changes in permittivity to changes in weight and the times
fails to establish a clear relationship between permittivity and hydration. Assessing
the subtle changes in hydration found in a population of sedentary, healthy adults
proves difficult. More work is required to determine approaches suitable for tracking
subtle changes in hydration over time with microwave-based hydration assessment techniques.
The food intake among 62 Lebanese adults observant of RF has been compared to their
intake for the rest of the year.[7] Participants completed multiple 24-hour dietary recalls, and dietary intake was
examined for food groups, energy, macro, and micronutrient consumption. The study
highlighted major differences in dietary intake between the fasting month and the
rest of the year. With the large number of adults who observe RF, the particularities
of dietary intake during Ramadan should be considered in developing context and culture-specific
dietary recommendations. The experiences of young adult women observing RF were explored
to understand its impact on their body image and eating behaviors.[8] In-depth interviews were conducted with 14 young women at two-time points during
and after Ramadan. The questions were related to motivations, experience, eating behaviors,
and thoughts related to body image and appearance. Three themes emerged: (1) family
and community expectations to fast, (2) exerting control of eating behaviors, and
(3) preoccupation with weight and appearance. These results suggest that family and
community play a strong role in motivating women to fast during Ramadan, alongside
the need to feel a sense of belonging to their community. Furthermore, five systematic
reviews and meta-analyses addressed various physiological and nutritional questions
on RF. The question of whether intermittent fasting enhances weight loss or muscle
gains in humans younger than 60 years old was also addressed.[9] Ten original articles were evaluated. Eight studies were randomized controlled trials,
and the other two were cross-sectional studies. These suggested that RF could be beneficial
in resistance-trained subjects or overweight people to improve body composition by
decreasing fat mass and at least maintaining muscle mass, decreasing glucagon-like
peptide-1 levels, and improving health-related biomarkers. However, future studies
are needed better to elucidate the effect of intermittent fasting on body composition.
Possible effects of RF on the main hormones regulating appetite and satiety, including
leptin and adiponectin, were examined.[10] Sixteen eligible studies were included in the systematic review, and 10 of them
with complete data on leptin and adiponectin were included in the meta-analysis. A
significant decrease in leptin levels was observed after RF. However, RF had no significant
effect on adiponectin levels. Subgroup analysis demonstrated a greater decrease in
leptin levels among normal-weight subjects than those of overweight/obese subjects.
Thus, RF may decrease leptin levels, especially in normal-weight subjects. There was
high heterogeneity, which may be explained by the differences between the wide range
of study conditions. Studies on the effects of Ramadan versus non-RF on body composition
were reviewed.[11] Sixty-six articles met the eligibility criteria. Non-RF was found effective for
decreasing body weight, BMI, and absolute fat mass. When contrasting pre- to postintervention
data on fat-free mass between treatments and controls, group differences were nonsignificant.
Conversely, they observed a significant increase in fat-free mass when comparing pre-
to postintervention. Finally, despite being accompanied by dehydration, RF is effective
in decreasing body weight and relative fat mass. RF seems to implicate some beneficial
adaptations in weight management, although non-RF appears to be more effective in
improving overall body composition. Omentin is an adipokine with anti-inflammatory
and insulin-sensitizing effects that can play a protective role against cardiovascular
disease (CVD) and diabetes. The association between overall dietary intake and omentin
gene expression and circulation was investigated.[12] Twenty relevant studies were included; six were observational and eleven were human
clinical trials. In the observational studies, omentin serum concentration was reduced
by RF and saturated fatty acid intake. An increase in omentin gene expression was
observed with monounsaturated fatty acid intake. There was no association between
dietary inflammatory index, macronutrient intake, total calorie intake, and omentin
plasma concentrations. In the human interventional studies, omentin plasma concentration
increased with a long-term low-calorie, low-fat diet, and no change was seen with
an high-fat diet or a short-term low-calorie diet. The authors suggested that a long-term
diet with a lower fat content and a balanced distribution of fatty acids may effectively
increase omentin plasma concentration, possibly via improved insulin resistance and
reduced inflammation. However, more work is needed to confirm or refute this. Finally,
the effects of two patterns of time-restricted eating (TRE), traditional TRE and RF,
on two markers of circadian rhythm, cortisol, and melatonin, were reviewed.[13] Fourteen studies were included. All RF papers found a significant decrease in melatonin
during Ramadan. Two out of the three papers on RF noted abolishing the circadian rhythm
of cortisol. However, the non-Ramadan TRE papers did not examine melatonin and mixed
cortisol changes. In studies comparing TRE to control diets, increased cortisol levels
in the non-TRE fasting group were found in one study, and no difference was found
in another. Dinner-skipping resulted in significantly reduced evening cortisol and
nonsignificantly raised morning cortisol. Conversely, breakfast skipping resulted
in significantly reduced morning cortisol. This blunting indicates a dysfunctional
hypothalamic–pituitary–adrenal axis and may be associated with poor cardiometabolic
outcomes.
Impact of RF on Cardiovascular Disease and Risk Factors
The impact of RF on the cardiovascular system included studies on hypertension, cardiac
function, and cardiovascular risk factors, including BP variability and endothelial
dysfunction. Two independent sets of recommendations were produced in 2021.
The effect of fasting on ambulatory BP and heart rate in treated hypertensive subjects
in Tunisia (2019) was examined in 60 hypertensive patients.[14] During Ramadan, the most patient took their treatment once daily. Average 24-hour
ambulatory BP, daytime and nighttime mean values of systolic and diastolic BP, and
heart rate were not different, regardless of age, sex, medical history, and lifestyle.
Also, the prevalence of overweight-obesity, the degree of compliance with dietary
recommendations, and the effects of RF on cardiovascular health were examined among
26 women (aged 33.6 years) living in the City of Melilla, North Africa.[15] All participants were overweight or obese; however, more than 60% considered their
weight appropriate or low. By the end of Ramadan (ER), the women's BMI and fat component
values had fallen significantly, but this loss was recovered later. Dietary records
revealed excessive consumption of lipids and sodium and high waist-to-hip ratio. All
these factors are related to cardiovascular risk. The authors concluded that promoting
nutritional health and encouraging year-round self-care among adult Muslim women is
necessary to ensure healthy fasting during Ramadan. The effect of RF on BP, fatigue,
sleeping, and physical activity was tested among 1,118 hypertensive patients.[16] There were significant differences between males and females regarding age, educational
level, occupational status, income, smoking habits, physical exercise, sports activities,
and fatigue. There were significant differences in the biochemistry parameters regarding
vitamin D, blood glucose, hemoglobin A1c (HbA1c) level, creatinine, bilirubin, albumin,
total cholesterol, triglycerides, high-density lipoprotein-cholesterol (HDL-C), low-density
lipoprotein-cholesterol (LDL-C), uric acid, and SBP for both males and females after
Ramadan as compared to BR. Also, BMI was significantly lower AR than BR. Thus, the
study confirmed that RF does not affect BP, blood glucose, HbA1c level, sleep quality,
fatigue, and BMI among hypertensive patients.
The effect of fasting on cardiovascular outcomes in hypertensive patients was reviewed
in several major databases.[17] The review included studies assessing Ramadan, intermittent, and water-only fasting.
Water-only fasting reduces body weight, BP, and lipolytic activity of fasting hypertensive
patients without affecting the average heart rate. RF enhances lipid profile, although
it shows conflicting results for body weight, BP, and heart rate variability. The
LORANS (London Ramadan Study) is an observational, systematic review, and meta-analysis.[18] In LORANS, the systolic blood pressure (SBP) and diastolic blood pressure (DBP)
of 85 participants were measured before and right after Ramadan. In the systematic
review, studies were retrieved from several databases. The authors meta-analyzed the
effect of these studies and unpublished data from LORANS. They included observational
studies that measured SBP and/or DBP BR and during the last 2 weeks of Ramadan or
the first 2 weeks of the month after. At least two reviewers conducted data appraisal
and extraction in parallel. They pooled SBP and DBP using a random-effects model.
In LORANS, 85 participants were recruited; the mean age was 45.6 years, with equal
sex distribution. SBP and DBP after RF were lower, even after adjustment for potential
confounders. They identified 2,778 studies, of which 33 with 3,213 participants were
included. SBP and DBP AR/BR decreased. In subgroup analyses, lower BPs were observed
in healthy groups or those with hypertension or diabetes but not in patients with
chronic kidney disease (CKD). The authors suggested a beneficial effect of RF on BP
independent of changes in weight, total body water, and fat mass. They supported recommendations
for professional guidelines that describe RF as a safe religious practice concerning
BP. Also, a systematic review and meta-analysis were conducted to measure the effect
sizes of changes in cardiometabolic risk factor (CMRF) in healthy adults observing
RF.[19] They identified 91 studies (4431 adults; aged 18–85 years) conducted between 1982
and 2020 in 23 countries. Meta-regression revealed that the age of fasting people
was a significant moderator of changes in HDL-C and LDL-C. Male sex was the only significant
moderator of changes in LDL-C. The fasting time duration was the only significant
moderator of HDL-C at the ER. RF positively impacts CMRF, which may confer short-term
transient protection against CVD among healthy people.
The impact of RF on lipid profile and cardiovascular risk factors in patients with
stable coronary heart disease was examined in a prospective observational study in
Tunisia (2020).[20] Eighty-four patients with stable ischemic heart disease who intended to fast were
enrolled. They included 79 males and had a mean age of 57 years. Detailed clinical
and biochemical assessments were performed BR and AR. Levels of cholesterol, triglycerides,
low-density lipoprotein-cholesterol, and apoprotein A significantly improved AR fasting
compared to their BR values. There was a significant decrease in blood fasting glucose,
insulin level, homeostasis model assessment of insulin resistance index, and hs-CRP
level. In patients with stable ischemic heart disease, RF may be accompanied by improved
lipid profile and glycemic parameters without an increase in coronary events.
The impact of fasting on cardiac health and heart rate variability as a measure of
cardiac stress was evaluated in 58 patients with controlled hypertension in a prospective
cohort during and after RF.[21] Lipid panel and blood glucose were measured at the end of each phase. BP and heart
rate variability were monitored on each follow-up day's morning, afternoon, and evening.
The mean age was 54 years, and 52% patients were males. Fasting did not affect hypertensive
subjects' body composition, lipid panel parameters, and BP; males only presented lower
body weight and hip circumference during Ramadan. Blood glucose was significantly
higher during Ramadan. Fasting significantly increased heart rate variability during
the afternoon period. Ramadan intermittent fasting reduces cardiac stress among hypertensive
patients controlled by an adherent to hypertensive medication without affecting their
hypertensive state.
Whether RF can improve endothelial dysfunction was documented via the thrombolysis
in myocardial infarction (TIMI) frame count method in angiography, including 67 patients
diagnosed with slow coronary flow by coronary angiographic BR.[22] All of them were re-evaluated via TIMI frame count within 1 to 3 months after Ramadan.
They tested their hypothesis that fasting may improve endothelial dysfunction in the
study's TIMI frame count method. TIMI frame counts were measured angiographically
from left anterior descending, circumflex artery, and right coronary artery, and they
were significantly lower than the counts before fasting. All coronary frame count
parameters showed significant improvement after Ramadan compared with the baseline
values before the RF period. Their results revealed that fasting and lifestyle changes
during Ramadan might be beneficial for improving endothelial dysfunctions in patients
with the slow coronary flow. This can be shown easily using the TIMI frame count.
This is a practical and easy method for showing coronary functions.
Recommendations for CVD patients during Ramadan were published by two groups in 2021.[23]
[24] The first group reviewed the literature to help healthcare professionals educate,
discuss, and manage CVD patients who are considering fasting. They recognized that
studies on the safety of RF in patients with cardiac disease are sparse, observational,
have a small sample size, and have short follow-ups.[23] However, they risk-stratified patients into 'low or moderate risk,' for example,
stable angina or nonsevere heart failure; “high risk,” for example, poorly controlled
arrhythmias or recent myocardial infarction; and “very high risk,” for example, advanced
heart failure. The “low-moderate risk” group may fast, provided their medications
and clinical conditions allow. The “high” or “very high-risk” groups should not fast
and may consider safe alternatives such as nonconsecutive fasts or shorter days, for
example, during winter. All fasting patients should be educated BR on their risk and
management (including the risk of dehydration, fluid overload, and terminating the
fast if they become unwell) and reviewed after Ramadan to reassess their risk status
and condition.[23] They called for further studies to clarify the benefits and risks of fasting on
the cardiovascular system in patients with different cardiovascular conditions to
help refine these recommendations. The second group convened by the Turkish Society
of Cardiology produced another consensus report.[24] They classified the patients as low and high risk according to their diseases and
symptom status. Patients with high risk are advised not to fast during Ramadan. They
advised that patients with low risk can fast during Ramadan, but their eligibility
for fasting should be assessed individually.[24] Also, pre-Ramadan clinical assessment is an essential component of the management
of patients with CVD. This should be focused on assessing multiple factors, including
age, fragility, functional capacity, symptoms, lifestyle, medications, and other concomitant
diseases such as diabetes or CKD. The potential risks and benefits of fasting should
be discussed with the patient, and the final decision to fast or not should be clarified
individually with a patient-centered approach. It is also essential to follow up with
low-risk patients who are determined to fast during Ramadan so that breaking the fast
is advised if the clinical situation change.
Impact of RF on Gastrointestinal and Hepatic Function
This year's work has focused on the interplay of RF and two aspects (a) gut microbiome
and (b) liver disease. The RF consequence on gut bacterium (Bacteroides and Firmicutes),
serum concentration for butyrate, and lipid profile were investigated in thirty healthy
subjects BR and ER.[25] Fasting blood samples were obtained to measure fasting blood sugar, lipid profile,
and serum butyrate concentration. Anthropometric variables were measured BR and AR
for all 30 subjects. Serum levels of butyrate significantly increase during the month.
The gut Bacteroides and Firmicutes increased by 21 and 13% after Ramadan. The increment
in Bacteroides occurred in both sexes, but Firmicutes significantly increased only
in women. Food intake was decreased during Ramadan. RF caused a significant reduction
in BMI. Serum levels of LDL, HDL, LDL/HDL ratio, and total cholesterol significantly
decreased during Ramadan. The authors concluded that promoting Bacteroides and Firmicutes
in the gut might play a crucial role in health promotion. However, more research is
needed to achieve a definite conclusion. Also, the effects of RF on the gut microbiome
were examined.[26] Feces, blood samples, and longitudinal physiologic data in two cohorts sampled in
two different years were examined. The fecal microbiome was determined by 16S sequencing.
Results were contrasted to age- and body-weight-matched controls and correlated to
physiologic parameters. RF increased microbiome diversity and was explicitly associated
with upregulation of the Clostridiales order-derived Lachnospiraceae and Ruminococcaceae
bacterial families. Microbiome composition returned to baseline upon cessation of
intermittent feeding. Furthermore, changes in Lachnospiraceae concentrations mirrored
RF provoked changes in physiologic parameters. RF provokes substantial remodeling
of the gut microbiome. They proposed that RF-provoked upregulation of butyric acid-producing
Lachnospiraceae provides an obvious possible mechanistic explanation for health effects
associated with RF. Furthermore, whether RF altered the microbiota in Chinese and
Pakistani individuals was investigated.[27] Using high-throughput 16S rRNA gene sequencing and self-reported dietary intake
surveys, they determined that the microbiota and dietary composition were significantly
different with little overlap between ethnic groups (Pakistani and Chinese). Measurement
of alpha diversity showed that RF significantly altered the coverage and Albumin,
CRP, Endoscopy (ACE) indices among Chinese subjects but incurred no changes among
either group. Specifically, Prevotella and Faecalibacterium drove the predominance
of Bacteroidetes and Firmicutes in the Pakistani group, while Bacteroides (phylum
Bacteroidetes) were the most prevalent among Chinese participants both before and
after fasting. They observed significant enrichment of some specific taxa and depletion
of others in individuals of both populations, suggesting that fasting could affect
beta diversity. Notably, Dorea, Klebsiella, and Faecalibacterium were more abundant
in the Chinese group after fasting, while Sutterella, Parabacteroides, and Alistipes
were significantly enriched after fasting in the Pakistani group. Evaluation of the
combined groups showed that genera Coprococcus, Clostridium_XlV, and Lachnospiracea
significantly decreased after fasting. Analysis of food intake and macronutrient energy
sources showed that fat-derived energy was positively associated with Oscillibacter
and Prevotella but negatively associated with Bacteroides. In addition, the consumption
of sweets was significantly positively correlated with the prevalence of Akkermansia.
The study indicated that diet was the most significant influence on microbiota and
correlated with ethnic groups, while fasting increased specific bacterial taxa in
some individuals. Given the dearth of understanding about the impacts of fasting on
microbiota, their results provide valuable inroads for future studies aimed at novel,
personalized, behavior-based treatments targeting specific gut microbes for the prevention
or treatment of digestive disorders. Finally, a systematic review aimed to provide
an overview of the existing animal and human literature regarding the gut microbiota
alterations in various fasting regimens.[28] The findings suggest that different fasting regimens, including alternate-day fasting,
calorie- and time-restricted fasting programs, and RF, could promote health perhaps
through the modulation of the gut microbiome. However, further studies are needed
to explore correctly the connection between gut microbiota and meal frequency and
timing.
Nonalcoholic fatty liver disease (NAFLD) is an important public health condition.
Firstly, the impact of RF on nonalcoholic steatohepatitis (NASH) severity scores were
examined in a retrospective, case–control study conducted between 2017 and 2019.[29] They included NAFLD patients who had been diagnosed by abdominal ultrasonography.
The study population was divided into two matched groups: NASH subjects who fasted
all of Ramadan and NAFLD/NASH subjects who did not fast (control). Metabolic/NASH
severity scores, homeostatic model assessment of β-cell function and insulin resistance
(HOMA-IR), NAFLD fibrosis score (NFS), BARD scores, and fibrosis-4 (FIB4) scores were
assessed in both groups BR and AR month. The study included 155 NASH subjects, of
whom 74 fasted. Among the fasting group, BMI decreased, NFS declined, BARD scores
declined, and FIB4 scores declined. C-reactive protein (CRP) decreased. Moreover,
HOMA-IR improved. Therefore, RF improved inflammatory markers, insulin sensitivity,
and noninvasive measures for NASH severity assessment. Also, a systematic review and
meta-analysis will estimate the effect size for changes in liver function tests (LFT)
in healthy people practicing RF and examine the impact of different covariates using
subgroup analysis and meta-regression.[30] They concluded that RF induces significant but small (aspartate transaminase, alkaline
phosphatase, bilirubin)-to-medium positive changes on LFT. They may confer transient,
short-term protection against fatty liver disease in healthy subjects. On the other
hand, advice and recommendations based on the available evidence were constructed
by an Egyptian.[31] They aimed to answer the research question: Do adult Muslim patients with different
liver diseases who fast during Ramadan have a deleterious effect on their health compared
to those who did not fast? Relevant publications were retrieved. Although RF was beneficial
for patients with NAFLD, it was deleterious to patients with Child B and C cirrhosis
and patients with peptic ulcers. Patients with chronic hepatitis, Child A cirrhosis,
and those with noncomplicated liver transplants can fast with prefasting assessment
and strict follow-up.
RF and Renal Medicine in CKD
Five studies/reviews during 2021 considered various aspects of CKD during Ramadan,
covering the impact on CKD, the perspective of physicians and patients with CKD/dialysis,
and the impact of RF on renal stones. The effect of RF on some markers of chronic
inflammation was evaluated in 20 CKD patients, mean age 61.9 years, with an estimated
glomerular filtration rate (eGFR) less than 60 mL/min/1.73 m2 body surface area and not on dialysis.[32] RF was not associated with a significant change in SCr, eGFR, serum albumin, body
weight, BMI, body fat, visceral fat, muscle mass, or body water. There was a significant
decrease in several markers of chronic inflammation. Therefore, RF was associated
with improvement in the state of chronic inflammation with no significant change in
body composition or deterioration of renal function tests in CKD patients. However,
the effect of fasting during Ramadan on kidney functions was examined in 130 patients
with CKD (stage III–IV CKD) admitted in Ramadan of 2019.[33] The median BUN decreased significantly after Ramadan. There was a significant difference
between the nonfasting groups BR and AR concerning creatinine levels. Median creatinine
increased significantly after Ramadan. There was a statistically significant difference
between the fasting groups BR and AR concerning creatinine levels. In conclusion,
RF does not deteriorate kidney functions and leads to a moderate improvement in kidney
function. From a different angle, the experiences and perceptions of hemodialysis
(HD) patients observing RF from three HD centers in Malaysia were studied using an
exploratory qualitative approach.[34] Four major themes emerged from the data (a) “fasting experiences,” (b) “perceived
side effects of fasting,” (c) “health-seeking behavior,” and (d) “education and awareness
needs.” Patients expressed the significance of RF and its perceived impact on their
health. A lack of health-seeking behavior among patients raised the need for awareness
and education related to RF. These patients' experiences and perceptions regarding
RF warrant effective communication between patients and healthcare practitioners through
structured-Ramadan-specific education programs.
Finally, a systematic review on the impact of RF on renal stone formation identified
10 observational studies, including 9,906 participants.[35] Nine of the studies were conducted in the context of RF, with the majority finding
that renal colic incidence was unaffected by RF. Two other studies noted that urine
metabolites and density were altered with fasting but did not translate into clinical
outcomes. Since RF is unlikely to significantly increase the risk of renal stones,
physicians should counsel higher-risk patients on safe fasting practices accordingly.
Thyroid and Adrenal Replacement Therapy in Ramadan
Endocrine research has focused this year on adrenal and thyroid replacement therapy.
First, the best time to instruct patients to take levothyroxine during Ramadan to
minimize changes in thyroid function tests (TFTs) during RF was investigated in a
prospective design.[36] Hypothyroid patients taking levothyroxine were randomized to receive instructions
to take levothyroxine at one of the following three times: at dusk 30 minutes before
Iftar meal, 3 or more hours after Iftar meal, or at dawn 30 minutes before suhour
meal. TFTs were performed 3 months before and within 6 weeks after Ramadan. Data from
patients with at least one blood test BR or AR were analyzed using mixed-effects regression
models. Plasma TSH levels were available at one or more time points for 148 patients.
The findings suggest that instructing patients to take levothyroxine at the time of
breaking the fast 30 minutes before the Iftar meal minimizes unfavorable changes in
plasma TSH post-Ramadan. In contrast, instructing patients to take levothyroxine 3 hours
post-Iftar or 30 minutes before suhour led to a greater rise in post-Ramadan TSH.
Second, cortisol and brain-derived neurotrophic factor (BDNF) have been shown to play
a role in mood, body composition parameters, and health-related quality of life (QoL).
Therefore, the mechanism of the benefit of RF, particularly on cortisol and BNDF,
and their association with mood and QoL were elucidated.[37] Insulin growth factor-1, interleukin-8, matrix metalloproteinase-9, and myoglobin
were determined in 34 healthy participants. Serum from peripheral venous blood samples
was collected at five time points: 1 week before RF (T1); mid of RF (T2), last days
of RF (T3), 1 week after RF (T4), and 1 month after RF (T5). The amounts of biological
mediators in the serum samples were determined. BDNF and cortisol significantly decreased
significantly at T3 and T4 compared to T1. The benefits of RF for mood-related symptoms
seem to be mediated by different biological mediators, notably cortisol and BDNF.[37]
Impact of RF on Neurological Conditions
In 2021, four studies addressed different neurological disorders during Ramadan. They
addressed headaches in general (1), migraine (2), and multiple sclerosis (MS) (1).
Headaches are a leading complaint during the Holy month of Ramadhan, and several studies
in the past have attributed the changing lifestyles and habits as some of the leading
triggers. Few recent studies have further elaborated on these findings. A new headache
that occurs within 4 hours of breaking the fast during Ramadan was characterized in
a cross-sectional study during the last 10 days of Ramadan, based on a random sample
of adults.[38] Out of 16,031 participants, 19.6% reported headaches after breaking the RF. In 84.1%
of cases, no previous diagnosis of headache or migraine was evident. The characteristics
of these postprandial fasting-related headaches were mostly episodic. The nature of
the headache was variable, mostly heaviness or tightness. Triggering factors included
ingestion of fried food and coffee. Lying down and sleeping was found to be a crucial
relieving factor. They concluded that a new headache entity appears to be quite common,
occurs less than 2 hours following the first meal, and is mainly of the heaviness
and tension-type. More specifically, two studies considered migraine during RF since
fasting is a known trigger for migraine. First, a retrospective study included patients
diagnosed with migraines to study the impact of RF and changing habits during Ramadan.[39] The frequency, severity of migraine attacks, and the number of analgesic days during
Ramadan were compared to those during the month before, the immediately preceding
month to Ramadan. The number of breaking fasts due to migraines was reported. The
study identified 293 migraineurs. Most of the patients were females (89.1%). Most
of their cohort had changed sleep and food habits during Ramadan (93.2%). Most patients
completed fasting for the whole month of Ramadan, and 36.5% broke their fasting for
some days. Most of their cohort (82.3%) continue on the same management plan for migraines
during Ramadan. Patients had a significant increase in migraine days compared with
the month before. Also, days of analgesic use and migraine severity increased during
Ramadan. In multivariate analysis, change in sleep and feeding habits with nonmodification
of the treatment plan BR predicted breaking fasting due to worsening migraine. Also,
migraine interfered with daily activities due to fasting during Ramadan. Second, a
prospective observational study performed further analysis of migraines during 2020
Ramadan.[40] Patients fill out a questionnaire using the visual analysis scale with variables
such as frequency, duration, and intensity of migraines. Out of 292 known migraineurs
with a mean age of 33 years, 75% were males, and half of these had migraines on the
first day of Ramadhan. The frequency was reported higher in the first days of Ramadhan
compared to the rest of the 20 days. Change in lifestyle habits like sleep and eating
patterns, habits alteration, and dehydration were the common triggers. The two migraine
studies concluded that (a) changes in sleep, food habits, and dehydration worsen Migraine
frequency and severity during Ramadan. (b) Ramadan's potential exacerbating effect
on the frequency of migraine attacks should be discussed with patients with migraine.
This effect appears to be limited to the first 10 days of Ramadan and then subsides
with successive days of fasting. Physicians should educate migraine patients who fast
to manage their headaches and habits before starting fasting.
The clinical course of MS during RF and the predictors of relapses and symptoms of
exacerbation were explored in a retrospective study of 153 patients.[41] Data were collected from charts and directly from patients. Those who experienced
relapses, exacerbation of symptoms, and development of new symptoms during RF had
significantly longer disease duration than those who did not experience worsening.
Also, the former group had a significantly higher expanded disability status scale
than the latter group. Worsening during RF was significantly higher in patients who
experienced relapses in the preceding year compared to those who did not.
Although larger studies are needed to confirm these findings, these studies are still
open to errors such as small sample size, and the sample was not controlled for age,
sex, ethnicity, occupation, and smoking. Despite the available evidence, chance or
bias might explain the findings, with recall bias, reporting errors, and selection
bias. Confounding factors such as socioeconomic factors, dietary habits, work schedules,
infections, inability to take medication appropriately, skipping meals, dehydration,
and environmental factors can also affect the results.
Effects of RF on Maternal and Fetal Health
Bernier et al[42] studied the relationship between RF and the risk of stillbirth for Arab women in
Canada in a retrospective cohort study using birth certificates between 1981 and 2017.
The exposure to RF in the first and second trimester, and the outcome was an early
or late stillbirth. They evaluated the association between RF and the risk of stillbirth,
adjusted models for maternal characteristics, and assessed associations by cause of
death. The study included 78,349 live births and 274 stillbirths. There were 3.5 stillbirths
per 1,000 pregnancies for women exposed to Ramadan between weeks 1 and 27 of gestation
and 3.4 per 1000 for unexposed women compared those exposed. In adjusted models, maternal
RF between weeks 1 and 27 was not associated with the risk of early or late stillbirth.
Relative risks for early stillbirth were 1.40 for Ramadan between weeks 15 and 21
and 1.38 for Ramadan between weeks 22 and 27. Relative to no exposure, Ramadan between
weeks 15 and 21 was associated with early stillbirth due to congenital anomalies in
unadjusted models. The authors concluded that there is no evidence that Ramadan is
associated with the overall risk of early or late stillbirth. The effect of prenatal
exposure to RF on outcomes, including stunting and underweight for children under
5 years, was examined in those born between 2003 and 2018 in Pakistan.[43] The study uses observational data from four rounds of the UN-supported Multiple
Indicator Cluster Survey data collected on 204,186 children. A multivariate logistic
regression analysis was conducted on the cross-sectional data of 179,943 children
under 5 to assess the risk of stunting or underweight according to the month of gestation
coinciding with Ramadan. They observed a significant increase in the risk of stunting
and underweight associated with exposure to Ramadan following an inverted-U pattern.
The peak impact of Ramadan exposure on an underweight child occurs in the third month
of pregnancy. The probability of being underweight is 20% higher compared to children
whose gestation did not coincide with Ramadan. The peak impact of RF exposure on stunting
occurs in the fourth month of pregnancy, where the probability of stunting is 22%
higher compared to children whose gestation did not coincide with Ramadan. The results
varied a little by sex. In contrast, exposure to Ramadan in the 9th month of gestation
is associated with a reduced risk of stunting for boys and being underweight for both
boys and girls. Therefore, this analysis indicates that prenatal exposure to Ramadan
during the first two trimesters has negative implications for children's growth, highlighting
the critical role of maternal nutritional habits during early pregnancy for the long-term
physical development of children. Whether RF-associated nutritional insufficiency
could manifest as changes in height during childhood, long before any effects on aging
or disease risk at older ages, was evaluated in Iran.[44] Children exposed and those not exposed to RF in utero were compared to identify
any systematic difference between their parents' and households' characteristics.
The association of child height with prenatal exposure to Ramadan was measured, controlling
for seasonality and parent and household. Maternal RF in the second trimester of gestation
was associated with a 0.091 age-adjusted SDS decrease in children's height at age
10. The negative association was largest in male children and was approximately 1 cm
at age 12 years or older among male children. Maternal RF in the second trimester,
the critical period for long bone development, was associated with decreased height.
Fasting practices, beliefs, food group consumption, and minimally adequate dietary
diversity were studied in 852 women by RF occurrence and fasting adherence using logistic
regression with Hindu women as a seasonal control.[45] During Ramadan in 2018, 78% of pregnant women fasted every day. Over 80% of Muslim
women believe that they should fast during pregnancy, and over 50% expect positive
health effects on the mother and the unborn child. They found strong evidence that
Muslim women have more diverse diets during Ramadan, with higher odds and increased
consumption of pulses, dairy, fruit, and large fish. Dietary diversity increased to
a lesser extent on nonfasting days during Ramadan. Ramadan appears to improve dietary
quality in both fasting and nonfasting Muslim women in a rural population in Bangladesh.
These results may help interpret findings from studies on Ramadan during pregnancy
on later-life outcomes and thus contribute to a better understanding of intrauterine
influences of maternal nutrition on healthy child development. Furthermore, the perception
and knowledge of women about RF and maternal effects of fasting were studied in a
prospective, case–control design during Ramadan of 2020.[46] Pregnant women with spontaneous conception and singleton pregnancies who fasted
for 7 or more days (92 women) were cases, and those who did not fast (65 women) were
taken as controls. The questionnaire was filled out regarding the perception of women
about maternal fasting. Only 2.8% of women knew that fasting is forbidden in pregnancy. Sixty-five percent of women reported weakness as the main reason for
not fasting. He concluded that gestational diabetes, pregnancy-induced hypertension,
and preterm delivery were numerically but not significantly higher among women who
fasted compared to nonfasting women. There was no difference in anthropometric measurements
of newborn children among both groups
Two systematic reviews addressed the impact of RF on maternal and fetal health.[47]
[48] First, research on any long-term outcome of in utero Ramadan exposure was reviewed,
excluding maternal and perinatal outcomes. Sixteen studies were included.[47] Most studies suggest negative consequences from in utero Ramadan exposure on health
and economic outcomes later in adulthood. Higher under-five mortality rate, higher
mortality under three months and one year, shorter stature, lower BMI, increased incidence
of vision, hearing, and learning disabilities, lower mathematics, writing, and reading
scores, as well as a lower probability to own a home were associated with Ramadan
exposure during conception or the first trimester of pregnancy. Furthermore, age and
sex play a pivotal role in the association. Existing studies suggest that in utero
Ramadan exposure may adversely impact long-term health and economic well-being. However,
evidence is limited. Meanwhile, increasing awareness of the potential risks of RF
during pregnancy should be raised among pregnant women, and clinicians and other antenatal
care workers should promote better maternal healthcare. Second, the effects of RF
on the offspring of mothers, particularly on fetal growth, birth indices, cognitive
effects, and long-term effects, were investigated.[48] Studies were evaluated based on a predefined quality score, and 43 articles were
included. The study quality had a mean score of 5.4 (range 2-9). Only three studies
had a high-quality score (>7), of which one found a lower birth weight among fasting
women. Few medium-quality studies found a significant adverse effect on fetal growth
or birth indices. The quality of articles that investigated cognitive and long-term
effects was poor. The association between RF and health outcomes of offspring is not
supported by solid evidence suggesting that larger prospective and retrospective studies
with novel designs are needed.
Impact of RF on Rheumatology, Hematology, and Oncology Practices
A miscellaneous group of articles addressed various rheumatology, hematology, and
oncology problems. The sustainability of RF effects on rheumatoid arthritis (RA) activity
was evaluated in a prospective study including 35 patients with RA who observed RF
in 2019.[49] The disease activity was assessed and compared between three-time points: before(T1),
during (T2), and after (T3) Ramadan using the disease activity score 28 (DAS28). After
significantly decreasing all disease activity parameters between T1 and T2, a gradual
increase in clinical and biological outcomes was seen between T2 and T3. Except for
CRP, which was significantly higher at T3 (p = 0.02), the changes in the other disease activity parameters were not statistically
significant. By reference to baseline data (T1), the decrease in ESR, DAS28 CRP, and
DAS28 ESR induced after the Ramadan fast was maintained until T3, with statistically
significant differences. They can conclude that this study was conducted at the beginning
of the fading-out of the effects of RF and that the duration of 3 months may be the
recommended interval between fasting periods to maintain the positive effects of intermittent
fasting on RA activity. Therefore, RF can induce a rapid improvement in RA activity.
The positive effects of this model of fasting can last up to 3 months. The recommended
interval between fasting periods may be estimated at 3 months. The same group also
reviewed data that assessed the relationship of RF with rheumatic diseases.[50] They found that recent evidence indicates that RF may attenuate the inflammatory
state by suppressing proinflammatory cytokine expression and reducing body fat and
the circulating levels of leukocytes. Therefore, it may be a promising nonpharmacological
approach for managing the course of rheumatic inflammatory diseases. Despite differences
between studies on daily fasting duration and dietary norms, there appears to be a
consensus that most patients with RA or spondyloarthritis who fasted Ramadan experienced
relief from their symptoms. Nevertheless, further clinical trials are required to
assess the effect of RIF on other musculoskeletal and bone disorders. Additionally,
they evaluated the impact of RIF on chronic medication intake. Even if a few studies
on this issue are available, the primary outcomes indicate that RIF does not significantly
impair either compliance or tolerance to chronic medications. These findings may reassure
patients with a specific fear of drug intake during Ramadan.
Five studies reported the impact of RF on hematological practice. First, three studies
addressed the impact of RF on clotting and anticoagulant therapy. The alterations
in the anticoagulation response to warfarin and the associated risk factors were examined.[51] One-hundred eighty-three patients receiving warfarin for at least 1 year were included
in the study. Warfarin sensitivity index (WSI), prothrombin time international normalized
ratio (PT-INR) category, and time spent in therapeutic range (TTR) were assessed.
National Institute of Clinical Health Excellence (NICE) criteria for anticoagulation
status were adhered to where TTR (%) less than 65 was considered as poor anticoagulation.
No significant differences were observed in warfarin doses between the study participants
between pre-Ramadan, Ramadan, and post-Ramadan periods. Significantly more PT-INR
tests were carried out during Ramadan than pre- and post-Ramadan. A higher WSI was
akin to PT-INR, and lower intraindividual variability was observed in middle-aged
and older adults post-Ramadan. Significantly fewer patients had their PT-INR in TTR
and more in the subtherapeutic range during Ramadan. A greater proportion of patients
had PT-INR in the supratherapeutic range during post-Ramadan, particularly the elderly.
Although 38.3% had poor anticoagulation status overall, 92.4% met the NICE criteria
for poor anticoagulation during the 3 months (pre-Ramadan, Ramadan, and post-Ramadan
periods). RF influences the therapeutic effect of warfarin in terms of lowered TTR
(%), reduced proportion of patients achieving therapeutic PT-INR, and increased risk
of poor anticoagulation control. Also, Alwhaibi et al[52] evaluated the impact of RF on warfarin efficacy by investigating INR stability in
medically stable patients. A retrospective observational study was conducted during
Ramadan 2016 on fasting adult patients aged above 18 years and receiving warfarin.
The INR values during pre-Ramadan, Ramadan, and post-Ramadan periods were collected
after satisfying the inclusion criteria. Time within TTR during the whole period was
estimated using the conventional method. One hundred-one patients were 55.8 years
old, and 52.4% were females. An upward trend in the proportion of patients with therapeutic
INR was noticed during Ramadan (59.4%) as compared to the pre- (56.4%) and post-Ramadan
periods (53.5%), respectively. Additionally, the proportions of patients with supratherapeutic
and sub-therapeutic INR were the highest and lowest, 23% and 24%, respectively, post-Ramadan
compared to other periods. Achieving therapeutic INR during Ramadan was more feasible
with the low INR (2–3) compared to the high INR (2.5–3.5) target patients, 63.5 versus
52.6%, respectively. TTR estimation revealed that 62.4 and 37.6% of the patients had
excellent and poor anticoagulation status throughout the study period. Therefore,
the results confirm that short-term fasting during Ramadan has no significant influence
on INR stability and, consequently, therapeutic efficacy in warfarin-treated medically
stable patients. Batarfi et al[53] determined the patient-guided modifications of the oral anticoagulant (OAC) medication
regimen during Ramadan and evaluated its consequences in a multicenter cross-sectional
study (2019). Participants were patients who fasted Ramadan and who were on long-term
anticoagulation. Patient-guided medication changes during Ramadan compared to the
regular intake schedule BR were recorded. Modification behavior was compared between
twice daily (BID) and once daily (QD) treatment regimens. Rates of hospital admission
during Ramadan were determined. They included 808 patients. During Ramadan, 53.1%
modified their intake schedule (31.1% adjusted intake time, 13.2% skipped intakes,
and 2.2% took double dosing). A higher frequency of patient-guided modification was
observed in patients on the BID regimen compared to the QD regimen. The authors concluded
that patient-guided modification of OAC intake during Ramadan is common, particularly
in patients on the BID regimen. It increases the risk of hospital admission during
Ramadan. Planning of OAC intake during Ramadan and patient education on the risk of
low adherence is advisable.
Two studies were concerned with hematological oncology and radiotherapy. Yassin et
al[54] evaluated the effect of RF on patients with chronic myeloid leukemia receiving tyrosine
kinase inhibitors (TKIs) by evaluating specific clinical, hematological, and molecular
parameters in a 3-year retrospective study. Forty-nine patients were included, aged
46 years, 73.5% males. Imatinib was the most common TKI, used in 25 patients (51%).
The mean white blood cells, neutrophils, and BCR-ABL were reduced after fasting compared
to before and during with statistical difference. The use of TKIs while fasting did
not result in significant changes in hematological nor BCR-ABL levels in their study.
Patients who wish to practice intermittent fasting may be reassured in this regard,
yet physicians can adopt the safe trial approach, allowing the patients to fast, but
with instructions such as when to break fasting.
On the other hand, Lachgar et al[55] studied fasting practices in patients receiving external radiation therapy during
Ramadan 2018 in Casablanca. They included all patients who received external radiotherapy,
involving a total of 209 patients. Most patients had breast cancer (35.4) and gynecological
cancers (18.7%). All patients have fasted Ramadan before the diagnosis of cancer.
However, only 39.2% fasted during the treatment by radiotherapy, and 40% of patients
discussed the possibility of fasting with their oncologist. The disease stage was
the only factor related to the fasting status of patients.
Impact of RF on Athletes' Well-Being
The month of Ramadan may intersect with many sports events. Understanding the effects
of RF on physical performance is necessary to guide considerations for athletes. This
notion has stimulated an increasing interest in the impact of RF on the general welfare,
competitiveness, and safety of athletes, including its impact on sleep physiology.
In the past year, several original studies and systematic reviews were published.
The effect of RF on cognitive and physical performance and biochemical responses to
specific exercises was studied in elite 12 young female handball players BR, during
the first week of Ramadan, and during the last week of Ramadan (LWR) during Ramadan
of 2013.[56] A battery of tests was performed as follows: Hooper index, vigilance test, Epworth
sleepiness scale (ESS), five jump test (5-JT), modified agility T-test (MAT), maximal
standing ball-throw velocity test (MSBVT), and running-based anaerobic sprint (RAST)
test. Rating of perceived exertion (RPE) was recorded immediately after the RAST.
Blood samples were collected before, after, and during each exercise. The results
showed that ESS scores were higher during LWR than BR. Moreover, MSBVT time decreased
during LWR. Therefore, performance was enhanced. The power of three final sprints
from the RAST decreased significantly only during LWR compared to BR. RAST fatigue
index and RPE scores were higher during LWR than BR. The results also showed that
hematological measures, plasma osmolarity, and energetic markers were unaffected by
RF. Biomarkers of muscle damage were higher after the RAST only during LWR compared
to BR. The authors concluded that RF increased ESS and decreased RAST performances
associated with more significant muscle damage and fatigue, especially at LWR. These
previous alterations could be attributed to sleep disturbances and circadian rhythms
rather than nutritional deficiency or dehydration.
The effects of RF on the morning-evening difference were investigated in team-handball-related
short-term maximal physical performance.[57] With a counterbalanced study design, 15 elite female handball players underwent
the hand grip (HG), ball throwing velocity (BTV), modified agility T-test (MAT), and
repeated shuttle-sprint and jump ability (RSSJA) tests at 07:00 hours and 17:00 h,
1 week BR, and during the second (SWR) and the fourth week of Ramadan (4WR). The oral
body temperature (OBT) was monitored prior to exercise, and the RPEs scale was obtained
after RSSJA. The results showed that the time of the day affected OBT under all conditions.
The HG, BTV, and MAT test performances were higher in the evening than in the morning
BR. However, the diurnal variation noted in the HG and MAT tests was reversed during
the SWR and 4WR, while the BTV variation was blunted during the SWR and reversed during
the 4WR. The best RSSJA performance was observed in the evening BR. However, a reversal
of this diurnal variation was observed for the best and mean sprint times, which was
blunted by the mean jump height and sprint time decrease during Ramadan. Moreover,
RPE was influenced by the time of the day during the month of Ramadan. These findings
suggest that the diurnal variation in team-handball-related short-term maximal physical
performance may be reversed and/or blunted during RF.
The effects of the 4-week small-sided games (SSGs) training program during RF on changes
in psychometric and physiological markers were investigated in professional male and
female basketball players.[58] Twenty-four professional basketball players from the first Tunisian division participated
in this study. The players were dichotomized by sex, and both groups completed a 4-week
SSGs training program with three sessions per week. Psychometric and physiological
parameters were measured during the first week and at the end of RIF. Post-hoc tests
showed significant stress levels in both groups concerning physiological parameters
and significantly lower heart rates in favor of males at posttest. These results showed
that SSGs training at the ER negatively impacted the psychometric parameters of male
and female basketball players. Researchers and practitioners should consider these
sex-mediated effects of training during RF in basketball players when programming
training during Ramadan.
Furthermore, the effect of fasting on muscle function and the buffering system was
investigated.[59] Twelve male athletes with 8 years of professional sports experience (age 23.2 years,
BMI: 24.2 kg/m2) participated in the study. Muscle function, buffering capacity, and
RPE was measured during and after RF using the Biodex isokinetic machine, blood gas
analyzer, and RPE 6-20 Borg scale, respectively. Venous blood samples for pH and bicarbonate
(HCO3-) were measured during and after RF by using the Biodex isokinetic machine,
blood gas analyzer, and RPE 6-20 Borg scale, respectively. Samples were taken immediately
after 25 repetitions of isokinetic knee flexion and extension. Measures taken during
isokinetic knee extension during RF were significantly lower than those after RF in
extension peak torque, flexion peak torque, extension total work, extension average
power, flexion average power, blood HCO3-, and RPE. No influence of RF was found on the blood pH. Therefore, RF adversely affects
muscle function and buffering capacity in athletes. It seems that a low-carbohydrate
substrate during RF impairs muscle performance and reduces the buffering capacity
of the blood, leading to fatigue in athletes.
The effect of RF on decision-making was evaluated in Kung-Fu athletes.[60] Fourteen male Kung-Fu athletes (mean age = 19 years) completed two test sessions:
BR and ER. In the afternoon of each session, participants completed the ESS, Profile
of Mood States (POMS), and Pittsburg Sleep Quality Index (PSQI). Participants reported
subjective fatigue, alertness, and concentration. Additionally, all participants performed
video-based decision-making tasks. Results indicated that reaction time decreased
by 30% at ER versus BR. However, decision-making decreased by 9.5% in ER versus BR.
PSQI results indicated that quality sleep score, sleep duration, and sleep efficiency
were negatively affected at ER compared to BR. ESS was higher at ER compared to BR.
In addition, fatigue scores, estimated by the POMS and current subjective feelings
(i.e., fatigue, concentration, and alertness), were also negatively affected at ER
compared to BR. The authors suggested that RF was associated with an adverse effect
on sleep and decision-making, as well as feelings of fatigue, alertness, and concentration.
To test the hypothesis that daily physical activity could be reduced among Muslims
due to the inability to refuel and rehydrate in the fasting state, a cohort study
was designed among adults registered with the national physical activity community
program.[61] Data from a pedometer-based community program was used to extract 3 months of daily
step counts before, during, and after Ramadan for 6 years. A survey was conducted
among participants to determine fasting practice and other health and environmental
factors. A total of 209 participants completed the survey and provided valid data
on physical activity. During Ramadan, the average daily steps decreased significantly
among fasting participants (n = 151) and increased for the nonfasting participants (n = 58). Fasting participants preferred before sunset (33.8%) or evening (39.7%) timings
of physical activity. In contrast, nonfasting participants preferred the early morning
(34.5%). These data suggest that RF impacts daily physical activity behavior, and
interventions should focus on creating awareness of the importance of maintenance
of adequate physical activity during RF.
The effects of an additional SSGs training program were assessed during RF on technical
performance depending on changes in body composition, sleep habits, and RPEs.[62] Twenty-four professional male basketball players from the Tunisian first division
participated in this study. The players were randomly assigned to an intervention
group (n = 12) or an active control group (CG, n = 12). Both groups completed a 4-week SSG training program (three weekly sessions).
During the first and fourth weeks of the SSGs training, the two groups were evaluated
to detect changes in technical performance, dietary intake, body composition, sleep
quality index (PSQI) survey outcomes, RPE, heart rate (HR), and blood lactate concentration
[La]. During the 4WR period, body composition, dietary intake, sleep latency, sleep
duration, and HR significantly decreased only for intervention. However, RPE significantly
increased, and technical performances were negatively affected. Analysis adjusted
for the percentage of change in sleep duration, body mass, and RPE showed no significant
differences in either group. Therefore, the technical performance of professional
basketball male players is significantly affected at the ER independently of changes
in RPE, sleep habits, and body composition.
Another study involved two groups of soccer players from the Russian Premier League
(RPL) of similar age: the exposure group (EG) consisted of 13 Muslims abiding by religious
fasting, and the CG included 13 non-Muslim.[63] Using the Instant system, the running performance of each player was controlled
in the groups during matches from the RPL before and in the third week of Ramadan
(i.e., two matches for every player). None of the measured parameters demonstrated
significant changes in any match. Therefore, restrictions on diet and liquid intake
during Ramadan negatively influenced the running performance of elite Muslim professional
adult soccer players during daytime matches.
The effect of sleep quality on physical performance and the effect of work status
on physical performance during RF among athletes were investigated by two groups.
In the first study, the effect of RF on the physical performance of male professional
medium distance runners was evaluated, considering their sleep quality and work status.[64] Thirty-two athletes participated in this study in the summer of 2019. Data about
sociodemographics, training characteristics, sleep quality (PSQI), and physical performance
(Cooper Test; Harvard step test) were collected before and during Ramadan. The study
suggested that both the quality of sleep and physical performance of the athletes
deteriorated during Ramadan, with better quality of sleep having better physical fitness/performance
both before and during RF. Athletes who worked beside training achieved worse physical
fitness test results and worse sleep quality. The authors suggested that policies
aimed to improve physical performance in RF should consider the quality of sleep and
the work status of athletes. The second study evaluated the impact of RF on sleep
quality and daytime sleepiness in team sports referees.[65] Seventy-eight male amateur team sports referees participated in this study. Participants
responded to the Arabic version of the PSQI and the ESS questionnaires before (10-days
prior) and during (last 7 days) of the month of Ramadan. PSQI and ESS scores increased
significantly during Ramadan, with 83.3% of participants scoring equal to or more
than 5 in the PSQI. The percentage of participants suffering from severe excessive
daytime sleepiness increased during Ramadan. Sleep duration decreased during Ramadan
and was associated with a delay in bedtime and wake-up time. The score for daytime
dysfunction and subjective sleep perception, as components of the PSQI, increased,
whereas the score for the use of sleep medication decreased during versus BR. The
study suggests that RF impaired sleep quality and increased daytime sleepiness in
team sports referees. Future studies using objective assessment tools are warranted.
Two systematic reviews of RF and sports were conducted. The first investigated the
effects of RF on physical factors in football players and secondarily considered the
impact on domestic club football leagues.[66] They conducted a systematic review of studies of football (soccer) players, data
collected during and around Ramadan, and injury and/or performance data provided.
Twenty-two studies were included. Studies included some iteration of BR, during-Ramadan,
and after-Ramadan data. Common measures observed included RPEs, sprinting, sleep,
peak heart rate, jumping, Yo-Yo intermittent recovery tests, Wingate anaerobic test,
field-specific tests, and injury rates. Decreased physical performance was commonly
observed during late afternoon/evening testing (before breaking the fast) and high-intensity
exercise. Another group conducted a systematic review on the effect of RF on anthropometric,
metabolic, and fitness parameters in normal-weight adults and overweight and obese
individuals.[67] The search conducted through several major databases using various combinations
of keywords related to nutritional interventions and outcomes of interest. Twenty-three
full-text longitudinal randomized and nonrandomized controlled studies were reviewed.
The analysis indicated that RF can reduce BM and improve nutrient metabolism in both
normal- and overweight individuals. RF does not appear to alter protein synthesis
and fat-free mass nor hamper aerobic fitness and muscular performance among physically
active individuals, including athletes. The first review concluded that there seems
to be a performance deficit related to RF in Muslim football players. The authors
suggested further studies to explore the effects of RF on actual match demands and
for considerations to be made to accommodate Muslim football players who observe RF.
The second review considered RF as a more easily adaptable form of IF is a promising
dietary approach to improving body composition and metabolic health while maintaining
fitness and muscular function.
Finally, the effect of mental training through imagery on the competitive anxiety
of adolescent tennis players fasting during Ramadan was assessed.[68] This study was conducted with male tennis players, randomly allocated to the experimental
group (EG; n = 18) and age-matched controls (CG; n = 20), who watched historical Olympics videos, while EG performed mental training.
The competitive anxiety state assessment was recorded four times. The first measurement
was carried out 1 week BR, the second measurement during the first week of the month,
the third measurement at the end of the second week, and the fourth measurement during
the 4WR. These results revealed a significant interaction (time × groups) for all
competitive anxiety subscales. Higher intensity and direction scores for the cognitive
and somatic anxiety subscales during Ramadan were compared with BR for both groups.
Higher intensity and direction scores for both groups could be found for the cognitive
and somatic anxiety subscales during Ramadan compared with pre-Ramadan. This score
increase was greater for the CG than for the EG in the middle and at the ER. Finally,
the self-confidence subscale score revealed that intensity and direction scores were
lower during Ramadan compared with pre-Ramadan for the two groups. The score for self-confidence
intensity was higher for the EG compared with the CG at the ER. It was concluded that
mental imagery training was effective in reducing anxiety (cognitive and somatic)
and increasing self-confidence in the intensity dimension of adolescent tennis players
who fast during Ramadan.
The Interplay between COVID-19 and RF
The coronavirus disease 2019 (COVID-19) pandemic raised some special concerns in the
context of RF. The questions of whether fasting is safe to practice sport or physical
activities during the COVID-19 pandemic health crisis and what healthy lifestyle behaviors
while fasting would minimize the risk of infection. First, the dilemma of the COVID-19
pandemic and physical activity during RF was considered, and recommendations to the
fasting communities for safely practicing physical activity during the time of the
COVID-19 pandemic were provided.[69] They suggested that since COVID-19 lacks a specific therapy. RF and physical activity
could help promote human immunity and be part of the holistic preventive strategy
against COVID-19. Also, the impact of RF on COVID-19 mortality was evaluated using
national data.[70] Seventeen local authorities in England were identified for having Muslims make up
at least one-fifth of the population. Indeed, Muslim populations in these areas are
among the most deprived. The study found no detrimental effects of RF on COVID-19
deaths. The authors highlighted the previous claims that certain behaviors and cultural
practices of minority communities explain the increased exposure to the pandemic.
They argued that such claims are not evidence-based. Furthermore, there was debate
whether COVID-19 infection and vaccination will hamper Ramadan among the Muslim population
worldwide. The proportion of the Bangladeshi population who had adequate knowledge
and attitude towards COVID-19 risk of infections and vaccination during RF was evaluated
in a cross-sectional study.[71] Five hundred two adults (50.2% males and 49.6% living in urban areas) were assessed
by a face-to-face interview. About 72.5 and 76.30% had adequate knowledge and a positive
attitude regarding COVID-19 risk of infection and vaccination during RF. No or low
formal education was significantly associated with inadequate knowledge and poor attitude.
Also, current smokers reported a negative attitude.
The impact of RF on the immune system and COVID-19-related concerns were examined.[72]
[73]
[74] First, RF was proposed to have the potential to optimize the immune system function
against the virus during the pandemic as it suppresses chronic inflammation and oxidative
stress, improves metabolic profile, and remodels the gut microbiome.[72] On the other hand, maintaining good hygiene and supporting the immune system are
effective preventive approaches to dealing with COVID-19. Moderate exercise training
and proper nutrition are essential factors to support immune function. Lack of facilities,
poor health, and many traditions that lead to public community gatherings may have
made many Islamic countries susceptible to this dangerous virus. In such an unprecedented
situation, there are many Muslims who doubt whether they can fast or not. Therefore,
the proposal of usable exercise programs and effective nutritional strategies is imperative.
Second, the proposed effects of RF on the immune system, the effects of RF on resting
values, and responses of immunological/antioxidant biomarkers in elite and recreational
athletes, together with the critical health, nutrition, and exercise, advise that
fasting people need to follow in the event of a COVID-19 pandemic.[73] Finally, vaccine hesitancy has been reported among people and healthcare staff from
ethnic minorities. Presumably, Muslims may be more hesitant to receive a COVID-19
vaccination because they do not want to compromise their fast.[74] Hence, it was important for these groups to know that having vaccines intramuscularly
during fasting time does not nullify one's fast, and vaccination should not be delayed.
Healthcare advocates must work closely with Imam to disseminate this information.
Those fasting may also be concerned that potential side effects of vaccination may
make it challenging to maintain their fast. Clinicians and COVID-19 vaccinators can
advise those fasting to drink more clear fluids and take simple analgesia outside
fasting times to mitigate any side effects.
Fasting after Bariatric and Posttransplant Surgery
There are a few reports on RF-related issues in surgical practice. These are considered
postbariatric care and posttransplant care. First, the effect of RF on QoL in patients
who underwent sleeve gastrectomy.[75] The results suggested that RF caused significant weight loss in sleeve gastrectomy
patients. Besides, it did not adversely affect the QoL but increased social functioning.
Second, there are no clear recommendations regarding fasting after metabolic/bariatric
surgery (MBS). Hence, 61 expert metabolic/bariatric surgeons with experience managing
patients who fast after MBS from 24 countries voted on 45 statements regarding recommendations
and controversies around fasting after MBS.[76] A modified Delphi method was used, and an agreement/disagreement equal to or more
than of 70.0% was regarded as consensus. The experts reached a consensus on 40 out
of 45 statements after two rounds of voting; 100% of the experts believed that fasting
needs exceptional nutritional support in patients who underwent MBS. The decision
regarding fasting must be coordinated among the surgeon, the nutritionist, and the
patient. At any time after MBS, 96.7% advised stopping fasting in the presence of
persistent symptoms of intolerance. Seventy percent of the experts recommended delaying
fasting after MBS for 6 to 12 months after combined and malabsorptive procedures according
to the patient's situation and surgeon's experience, and 90.1% felt that proton pump
inhibitors should be continued in patients who start fasting less than 6 months after
MBS. There was consensus that fasting may help in weight loss and improvement or remission
of NAFLD, dyslipidemia, hypertension, and type 2 diabetes mellitus among over 85%
of experts. Third, recipients of solid-organ transplants (SOT) often ask healthcare
professionals for advice on fasting. Studies on the effect of fasting in transplant
patients have all been done in the MENA, where the average fasting duration is between
12 and 14 hours. In comparison, in temperate regions in the summer, fasting duration
can be as long as 20 hours. Fasting when patients have to take immunosuppression 12 hours
apart with slight time variation poses unique challenges. To this end, a decision-making
tool was developed to assist clinicians in discussing the risks of fasting in transplant
recipients, considering circumstances such as the COVID-19 pandemic.[77] They highlighted that SOT recipients wishing to fast should undergo a thorough risk
assessment 3 months BR. They may require medication changes and a plan for regularly
monitoring graft function and electrolytes to fast safely. Recommendations have been
based on very high risk, high risk, and low/moderate risk. Patients in the “very high
risk” and “high risk” categories should be encouraged to explore alternative options
to fastings, such as winter fasting or Fidyah. Those in the “low/moderate” category
may be able to cautiously fast with guidance from their clinician. Before the commencement
of Ramadan, all patients must receive up-to-date education on sick-day rules and instructions
on when to terminate their fast or abstain from fasting.
Eye Structure and Function
Three articles were published on eye structure and function during RF.[78]
[79]
[80] First, the effect of RF and dehydration on intraocular pressure (IOP) and biometric
parameters in primary open-angle glaucoma (POAG) patients was evaluated in a prospective
study. They included 30 eyes of 30 POAG fasting patients, 40 healthy participants,
and 40 nonfasting healthy individuals.[78] POAG patients had a higher IOP at 4 pm during the fasting period than was seen following
Ramadan. In addition, the diurnal reduction in IOP and central corneal thickness was
more minor in patients with POAG compared with healthy subjects. Second, the effects
of RF on diurnal superficial-deep parafoveal vessel density (pfVD) and nerve head
(NH)-radial peripapillary capillary (RPC) peripapillary vessel density (ppVD) were
measured using optical coherence tomography angiography (OCTA). Related urodynamic
and hemodynamic parameters were compared to the nonfasting period in 105 healthy individuals
(42 women and 63 men).[79] Their mean age was 34.4 years. OCTA was used to examine the superficial-deep pfVD
and NH-RPC ppVD after Ramadan. The parafoveal and peripapillary DVDs (except for NHpp-VD)
and IOPs were found to have decreased significantly throughout the day, both in fasting
and nonfasting periods. This study confirmed the diurnal changes in the IOPs, mean
ocular perfusion pressures, superficial-deep pfVDs, and NH-RPC ppVDs under dehydration
and normal terms.[80] The choroidal thickness and superficial and deep vessel density indices of fasting
healthy subjects were measured with an OCTA device and compared with nonfasting measurements
of 70 eyes of 35 healthy subjects aged 42.9 years. Although a significant increase
was noted in central choroidal thickness in the fasting period, no significant change
due to fasting was observed in the superficial and deep capillary plexuses. The authors
concluded that the choroidal layer might vary in thickness due to fasting-related
metabolic factors, while retinal vessels are more stable against such effects.
Impact of RF on Mental Well-Being
Several studies considered RF's impact on general mental well-being and pre-existing
mental health issues. The relationship was investigated between RF as a spiritual
factor with prolonged hunger and disordered eating behaviors in 238 fastings and 49
nonfasting adolescents in 2016.[81] Between the groups, there was no significant difference between energy intake, Eating
Attitudes Test-26 (EAT-26), and the Three Factor Eating Questionnaire-R18 (TFEQ-R18)
scores. Figure rating Scale (FRS) revealed that the groups' comparisons of their “ideal”
and self were not significantly different. In contrast, the gap between the figures
they think was healthy and closest to self was significantly higher among nonfasting
adolescents. Most adolescents (97.5%) reported fasting for religious purposes, whereas
only 3.4% for losing weight. The EAT-26 total scores were in the pathological range
in 16.8% of adolescents who fasted for religious purposes. The study suggests that
the motivation of adolescents to fast during Ramadan was due to spiritual decisions
rather than weight control or other factors, and RF was not correlated with disordered
eating behaviors or body image dissatisfaction. Second, the number of psychiatry hospitalizations
during Ramadan was compared to the other months of the lunar year.[82] A cross-sectional and retrospective study was conducted at a psychiatric hospital
in Tunisia over five lunar years (1434–1438). A substantial decrease in hospitalizations
during Ramadan was observed each year, followed by a constant increase during the
following month. Ramadan was the only lunar month with a consistently below-average
number of admissions. There has been a significant increase in the mean number of
monthly hospitalizations over the years. A general trend toward an increase in the
proportion of enforced hospitalizations has been noted. Therefore, Ramadan stands
out not only on a religious but also on a social level. Furthermore, 80 individuals
completed an ambulatory monitoring period and a laboratory assessment session. Participants
who were fasting during Ramadan were matched by sex and khat use status who completed
the study while not fasting.[83] Forty participants in each fasting group were included. Results from the ambulatory
study indicated that withdrawal symptoms were lower during evening hours in the fasting
group than in the no-fasting group. Stress-related changes in positive and negative
effects were flattened in the fasting group relative to the no-fasting group. Khat
users reported reduced BP responses relative to nonusers. These results demonstrate
that fasting reduces negative affect and withdrawal symptoms in khat users. Khat use
was related to blunted BP stress responses independent of fasting. A study of patients
with an established diagnosis of depression (100 men aged between 18 and 64 years)
was reported from Bahrain during Ramadan.[84] Fifty persons fasted (FG) and 50 personas did not fast (NFG). There were no significant
changes in depressive symptoms within the FG versus NFG after controlling for baseline
covariates. No adverse effects were reported in either group. The FG experienced significant
reductions in body mass, body fat, body surface area, and lean mass. RF did not negatively
affect depressive symptoms and improved body composition, suggesting short-term intermittent
fasting may be a safe dietary practice for adult males with depression.
During RF, people accept significant disruption in regular activities, including tobacco
smoking. Thus, daytime during Ramadan (before sunset) is likely associated with abstinence
symptoms emerging among tobacco smokers. The effect of fasting on cigarette smoking
and nicotine addiction during Ramadan was examined in a descriptive cross-sectional
survey of smokers who fast in Ramadan[85] using a questionnaire delivered through face-to-face interviews at several family
medicine clinics in Turkey. There were 354 persons with a mean age of 32.9 years.
A significant decrease in cigarette consumption during Ramadan was reported by 80.5%
of smokers. The number of smokers who had difficulty resisting the urge to smoke was
less in Ramadan than in non-Ramadan. Religious sentiments were reported as the most
critical reason for coping with nicotine abstinence (53.7%). In 14.7% of the cases,
participants stopped smoking during the whole period of Ramadan. Religious beliefs
and willpower were effective in helping people reduce or temporarily stop smoking.
Therefore, RF may play a significant role in changing smoking behavior. Also, the
hypothesis was tested by measuring tobacco/nicotine abstinence symptoms and cravings
among smokers of cigarettes or water pipes during Ramadan.[86] A cross-sectional survey-based study was conducted on a convenience sample of adults.
A total of 632 exclusive cigarette smokers and 161 exclusive waterpipe tobacco smokers
were included. After fasting and abstaining from tobacco during the day, approximately
75% of cigarette smokers and 20% of waterpipe smokers reported smoking within the
first 30 minutes. In addition, 10% of cigarette and 30% of waterpipe smokers reported
smoking within the first 60 minutes. No significant difference was found between cigarette
and waterpipe smokers in smoking urge. For nicotine craving and withdrawal, significant
differences between cigarette and waterpipe smokers were found when comparing mean
scores for (i) urge to smoke, (ii) craving for nicotine, (iii) hunger, (iv) desire
for sweets, and (v) depression/feeling blue. Therefore, waterpipe smoking is associated
with abstinence-induced smoking urge and withdrawal symptoms similar to cigarette
smoking. Further research on reducing tobacco smoking should include all forms of
smoking. On the other hand, most Muslims who use e-cigarettes fast the month of Ramadan,
which results in intermittent fasting. The severity of e-cig withdrawal symptoms among
users during RF was evaluated using a self-administered survey developed and validated
to solicit anonymous responses from e-cig users in Jordan through a cross-sectional
study (n = 523; 96.4% males; 86.4% aged between 18 and 40 years).[87] Severity scores of physical and psychological withdrawal symptoms were assessed
and calculated. Many participants replaced tobacco smoking with e-cig (53.5%) to help
them stop smoking. Over half of the participants experienced relatively weak physical
and psychological withdrawal symptoms during the fasting month. Many participants
(63.2%) preferred to engage with a busy schedule to tolerate the related withdrawal
symptoms they experienced. Ramadan offers an excellent opportunity for smokers to
quit, as the reported physical and psychological e-cig withdrawal symptoms were relatively
weak.
Finally, the perceptions of fasting exemptions, medication usage behavior, perceptions
of relationships with healthcare providers, and factors impacting health management
during Ramadan were examined in a qualitative study.[88] Twenty-five adults (men and women) with chronic diseases participated in four focus
groups using standard methods. Participants were asked open-ended questions about
their fasting ability, medication usage behaviors, healthcare access, and collaboration
with providers during RF. Prominent themes/subthemes were fasting exemption, fasting
nonexemption, nonoral medication use during Ramadan, healthcare provider involvement
during Ramadan, and factors impacting health management during Ramadan. The authors
concluded that (a) patients perceive fasting as an essential religious practice, so
they tend to self-modify their medication-taking behaviors, and (b) educating healthcare
providers about Muslim culture, especially their strong desire to fast, may lead to
better management of their medications and viewing pharmacists and other healthcare
providers as knowledgeable healthcare providers.
