A population based study of Ramadan fasting and acute coronary syndromes

Islamic fasting: cardiovascular disease perspective

INTRODUCTION

Ramadan is a month of obligatory fasting observed by the majority of 2 billion Muslims living around the globe. The guidelines for 'risk-free' fasting exist for chronic diseases, including diabetes mellitus, but recommendations for cardiovascular disease (CVD) patients are deficient due to the paucity of literature.

AREAS COVERED

Databases were screened to find relevant studies for an evidence-based consensus regarding the risk stratification and management of CVD. Using practical guidelines of the European Society of Cardiology (ESC), we categorized patients into low-, moderate-, and high-risk categories and proposed a pre-Ramadan checklist for the assessment of cardiac patients before fasting. Regular moderate-intensity exercise is recommended for most cardiac patients, which has been demonstrated to provide an anti-inflammatory and antioxidant effect that improves immune function.

EXPERT OPINION

In Ramadan, many physiological changes occur during fasting, which brings about a balanced metabolic homeostasis of the body. In addition, Ramadan fasting is a nonpharmacologic means of decreasing CV risk factors. As Islam exempts Muslims from fasting if they are unwell; therefore, patients with the acute coronary syndrome (ACS), advanced heart failure (HF), recent percutaneous coronary intervention (PCI), or cardiac surgery should avoid fasting.

The Association between Acute Myocardial Infarction-Related Outcomes and the Ramadan Period: A Retrospective Population-Based Study

Fasting throughout the Muslim month of Ramadan may impact cardiovascular health. This study examines the association between the Ramadan period and acute myocardial infarction (AMI)-related outcomes among a Muslim population. The data were retrospectively extracted from a tertiary hospital (Beer-Sheva, Israel) database from 2002–2017, evaluating Muslim patients who endured AMI. The study periods for each year were: one month preceding Ramadan (reference period (RP)), the month of Ramadan, and two months thereafter (1840 days in total). A comparison of adjusted incidence rates between the study periods was performed using generalized linear models; one-month post-AMI mortality data were compared using a generalized estimating equation. Out of 5848 AMI hospitalizations, 877 of the patients were Muslims. No difference in AMI incidence between the Ramadan and RP was found (p = 0.893). However, in the one-month post-Ramadan period, AMI incidence demonstrably increased (AdjIRR = 3.068, p = 0.018) compared to the RP. Additionally, the highest risk of mortality was observed among the patients that underwent AMI in the one-month post-Ramadan period (AdjOR = 1.977, p = 0.004) compared to the RP. The subgroup analyses found Ramadan to differentially correlate with AMI mortality with respect to smoking, age, sex, diabetes mellitus, and hypertension, suggesting the Ramadan period is a risk factor for adverse AMI-related outcomes among select Muslim patients.

[Maladies cardiaques et Ramadan : revue de la littérature]

We review the literature on the safety of fasting in cardiac patients. We examined the changes of blood pressure among hypertensive patients and the incidence of cardiac events during Ramadan in patients with coronary disease and heart failure. We also assess the modifications of INR levels in cardiac patients who take oral anticoagulant. We found that Ramadan fasting is safe in stable cardiac patients, even under several drugs. Fasting does not affect blood pressure. There is no difference in regards to cardiac event incidence between Ramadan and the non-fasting-months. The level of INR is slightly higher when fasting, it is thus recommended to monitor patients with high bleeding risk during Ramadan.

Does Ramadan fasting have effects on sleep, fatigue and blood pressure among patients with hypertension?

AIM

The aim of this study was to determine the effect of Ramadan fasting on blood pressure (BP), fatigue, sleeping and physical activity among hypertensive patients.

SUBJECTS AND METHODS

A cross-sectional study was conducted from April 2019 to July 2019. Of the total 1500 hypertensive patients approached, 1118 (74.5%) gave their consent. Data analysis included sociodemographics, lifestyle habits, anthropometric measurements and clinical biochemistry parameters at baseline, and after 3 months.

RESULTS

Out of 1118 subjects, 593(47.6%) were male and 653(52.4%) were female. There were statistically significant differences between males and females regarding age groups in years, educational level, occupational status, income, smoking habits, physical exercise, sports activities and fatigue. There were statistically significant differences for the biochemistry parameters regarding vitamin D, blood glucose, HbA1c level, creatinine, bilirubin, albumin, total cholesterol, triglycerides, HDL-C, LDL-C, uric acid and SBP for both males and females after the holy month of Ramadan as compared to before Ramadan. Also, BMI was significantly lower during the after month of Ramadan as compared to before Ramadan (P < 0.001). Multiple linear regression analysis results revealed that less hours of sleeping (P < 0.001), SBP (mmHg) (P < 0.001), DBP (mmHg) (P < 0.001), family size (P = 0.002), obesity BMI (kg/m2) (P = 0.013), fatigue (P = 0.022) and smoking cigarette (P = 0.029) were identified as statistically significant predictors of hypertensive patients with Ramadan fasting as contributing at higher risk factors.

CONCLUSION

This study confirmed that fasting during Ramadan has no effect on the BP, blood glucose, HbA1C level, sleep quality, fatigue and BMI among hypertensive patients.

An observational study of the occurrence of acute coronary syndrome (ACS) among jordanian patients: Identifying the influence of Ramadan Fasting

Introduction

Patients with Acute Coronary Syndrome (ACS) tend to face several health issues during the Holy month of Ramadan, due to the change in dietary patterns. This study aims to investigate the influence of fasting during Ramadan on the occurrence of ACS.

Methods

The study followed a retrospective observational design, and was conducted in King Abdullah University Hospital (KAUH) of Jordan, during the period of June 06, 2016 to Aug 08, 2016 and May 27, 2017 to July 27, 2017. Data was collected from a sample of 226 male and female patients, aged between 20 and 80 years with major diagnosis of acute coronary syndrome. Therefore, this is a case series of ACS patients.

Results

Findings of the study indicated that, Ramadan fasting is insignificantly related to the occurrence of ACS, since no significant difference was found in the incidence of hypertension (65%), diabetes (51.7%), unstable angina (56.6%) and coronary artery disease (CAD) (57.6%) findings during and after Ramadan respectively. Similar, findings were attained for patients' final diagnosis which had normal Kidney Function Test (KFT) (72.5%), platelets (91.5%), and Ejection Fraction (EF) (64.6%). Also, no significant difference was found between patients' smoking status (61.0%), hospital stay (89.8%) and discharge rate (96.9%).

Conclusion

The study concluded that there is an insignificant association of Ramadan fasting on the cardiac patients and occurrence of acute coronary syndrome.

The effect of Ramadan fasting on cardiovascular events and risk factors in patients with type 2 diabetes: A systematic review

Ramadan is the fasting month in Islam. Muslims around the world observe Ramadan every year, including people with diabetes. Data on the association of fasting in people with diabetes are sparse. The purpose of this study is to assess the association of fasting on cardiovascular risk factors and events in people with diabetes. A comprehensive search was conducted in the following database: Embase, Medline, Cochrane library and CINAHL. The following key terms were used: Ramadan, Ramazan, Ramadhan, Muslim, Islam and fasting. Studies were eligible if they included people with Type 2 diabetes who fasted during Ramadan and reporting results on cardiovascular risk factors or events. Overall 22 studies met inclusion criteria for the review; five studies reported cardiovascular outcomes and 17 reported changes in risk factors. There is insufficient evidence to link Ramadan fasting with increased or reduced incidence of cardiovascular events in people with diabetes, though there were some indication stroke risk may be increased. Findings were inconsistent in term of risk factors as some favoured Ramadan and others did not.‬‬‬‬.

Atrial Fibrillation in Middle Eastern Arabs and South Asians: Summary of Published Articles in the Arabian Gulf

Seven studies are summarized herein focusing on different aspects of Atrial fibrillation (AF) in two unique ethnicities for which there is very limited literature published before; Middle Eastern Arabs and South Asians, using data from a national registry of cardiovascular diseases in Qatar over a 20-years period (1991-2010). These studies shed light upon important aspects of AF presentations and outcomes in these two ethnicities, thereby enriching the world literature on AF. In the process, several novel observations were reported and new questions were raised that warrant further investigations.

Effect of ramadan fasting on glycemic control and other essential variables in diabetic patients

Background

Fasting during the holy month of Ramadan is a religious obligation for all Muslims who represent 1.8 billion of the world population (24%). This study explores the effect of Ramadan fasting on the blood glucose, glycated hemoglobin (HbA1c), lipid profile, sleeping quality, and essential lifestyle parameters and also explores the safety of fasting for a whole month among diabetic patients.

Aim

The aim of the present study was to assess the impact of Ramadan fasting on the blood glucose, HbA1c, lipid profile, sleeping quality, and lifestyle parameters among patients with type 2 diabetes mellitus (T2DM) in Turkey.

Subjects and Methods

A total of 1780 diabetic patients were approached, and 1246 (70%) participated in this cross-sectional study carried out during the period from May 27, 2017, to June 24, 2017. Data analysis comprised sociodemographic features, lifestyle habits, blood pressure measurements, serum lipid profiles, serum calcium, Vitamin D 25-hydroxy, uric acid, and HbA1c at before 4 weeks and after 12 weeks from Ramadan.

Results

Out of 1246 patients, 593 (47.6%) were male and 653 (52.4%) were female. The mean ± standard deviation age of the patients was 50.39 ± 15.3 years. Males were significantly older than females (51.53 ± 12.56 vs. 49.26 ± 14.4; P = 0.003, respectively). Significant differences were found in Vitamin D, blood glucose, HbA1c level, creatinine, bilirubin, albumin, total cholesterol, triglycerides, high-density lipoprotein-cholesterol (female), low-density lipoprotein-cholesterol (male), uric acid, and systolic and diastolic blood pressure after and before the holy month of Ramadan (P < 0.05 for each). HbA1c (P < 0.001), physical activity (P < 0.001), hours of sleeping (P < 0.001), systolic blood pressure (BP) (mmHg) (P = 0.007), BMI (P = 0.016), diastolic BP (mmHg) (P = 0.018), family history (P = 0.021), and smoking (P = 0.045) were identified as significantly associated with Ramadan fasting as contributing factors.

Conclusion

In one of the largest studies of its kind, we show that Ramadan fasting has positive effects on T2DM patients as it reduces their blood pressure, blood glucose, HbA1C, and BMI. Furthermore, there are improvements in the duration of sleep and physical activity, the role of Ramadan fasting in diabetes therapy has been confirmed.

Outcomes and hospital admission patterns in patients with diabetes during Ramadan versus a non-fasting period

BACKGROUND

Fasting during Ramadan is a challenge for Muslim patients with diabetes and for their healthcare providers. However, data on the effects of Ramadan fasting on hospital admissions and outcomes in patients with diabetes are scarce.

OBJECTIVES

Evaluate the characteristics of patients with diabetes admitted during the fasting month of Ramadan compared with the non-fasting month of Dhu al-Qidah.

DESIGN

A retrospective cohort study medical record review.

SETTING

A university teaching hospital.

PATIENTS AND METHODS

We reviewed the records of all patients with diabetes admitted to the medical department at Benghazi Medical Center, including medical ward, intensive care unit and coronary care unit, during the months of Ramadan and Dhu al-Qidah, 2016. We compared differences in reasons for admission, length of stay and in-hospital mortality between patients admitted during Ramadan and Dhu al-Qidah and between patients who were fasting at time of admission during Ramadan and those who were not.

MAIN OUTCOME MEASURES

Main reason for admission, length of stay and in-hospital mortality rate.

SAMPLE SIZE

402 patients with diabetes.

RESULTS

During Ramadan, 186 patients were admitted compared with 216 during Dhul al-Qidah. There was no statistically significant difference in reasons for admission, length of hospital stay, or in-hospital mortality (borderline for mortality, P=.078), between patients with diabetes admitted during Ramadan and Dhu al-Qidah. Of those admitted in Ramadan, 59.1% were fasting on admission. Fasting patients admitted during Ramadan had a significantly higher proportion of the diseases of the circulatory system when compared with non-fasting patients (39.4% vs. 23.6%, P=.028) while in-hospital mortality was higher in non-fasting patients (29.2% vs. 8.7%, P less than .001). There was no significant difference in length of stay between fasting and non-fasting patients.

CONCLUSIONS

The frequency of admissions for most medical con.ditions were not changed during Ramadan but the frequency of acute coronary syndrome was higher in those who were fasting on admission. Patients with diabetes who were not fasting on admission had more high-risk features that prevented them from fasting and therefore are at increased risk of in-hospital mortality.

LIMITATIONS

Single center and retrospective.

CONFLICT OF INTEREST

None.

The effects of fasting on heart rate variability in hypertensive patients

Heart rate variability (HRV) is an independent indicator of increased mortality in patients with myocardial infarction and congestive heart failure. The effects of fasting on the HRV are not known in hypertensive patients. Therefore, studying the effects of Ramadan fasting on hypertensive patients' HRV seems reasonable to address. We conducted a prospective study including 20 hypertensive patients with sinus rhythm. HRV was determined twice by ambulatory 24-hour Holter recordings at fasting during and after Ramadan. Subjects mean age was 55 ± 11.8 years. Sex-ratio was 1.5. When two groups compared, statistically significant differences were found in terms of SDNN (113 ± 71 vs 140 ± 38, p = 0.001), SDANN (109.7 ± 45 vs 134.8 ± 48.3, p = 0.008), T power (2368.7 ± 121.3 vs 3660.5 ± 170.9, p = 0.03) and LF (552.2 ± 31.3 vs 903.7 ± 48.9, p < 0.0001) values. HRV parameters were found to be decreased in Ramadan. Thus, Ramadan fasting enhances the activity of the sympathetic system in hypertensive patients.

Acute heart failure presentations and outcomes during the fasting month of Ramadan: an observational report from seven Middle Eastern countries

BACKGROUND

Fasting during the month of Ramadan is practiced by over 1.5 billion Muslims worldwide. It remains unclear, however, how this change in lifestyle affects heart failure, a condition that has reached epidemic dimensions. This study examined the effects of fasting in patients with acute heart failure (AHF) using data from a large multi-center heart failure registry.

METHODS AND RESULTS

Data were derived from Gulf CARE (Gulf aCute heArt failuRe rEgistry), a prospective multi-center study of consecutive patients hospitalized with AHF during February-November 2012. The study included 4,157 patients, of which 306 (7.4%) were hospitalized with AHF in the fasting month of Ramadan, while 3,851 patients (92.6%) were hospitalized in other days. Clinical characteristics, precipitating factors, management, and outcome were compared among the two groups. Patients admitted during Ramadan had significantly lower prevalence of symptoms and signs of volume overload compared to patients hospitalized in other months. Atrial arrhythmias were significantly less frequent and cholesterol levels were significantly lower in Ramadan. Hospitalization in Ramadan was not independently associated with increased immediate or 1-year mortality.

CONCLUSIONS

The current study represents the largest evaluation of the effects of fasting on AHF. It reports an improved volume status in fasting patients. There were also favorable effects on atrial arrhythmia and total cholesterol and no effects on immediate or long-term outcomes.

The Islamic tradition and health inequities: A preliminary conceptual model based on a systematic literature review of Muslim health-care disparities

OBJECTIVE

The objective of this study was to identify mechanisms by which Islamic beliefs, values, and Muslim identity might contribute to health inequities among Muslim populations.

METHODS

A systematic literature review of empirical studies in Medline from 1980 to 2009 was conducted. The search strategy used three terms covering health-care disparities, ethnicity, and location to uncover relevant papers.

RESULTS

A total of 171 articles were relevant based on titles and abstracts. Upon subsequent full-text review, most studies did not include religious identity or religiosity as explanatory variables for observed health disparities. Of 29 studies mentioning Islam within the text, 19 implicated Muslim identity or practices as potential explanations for health differences between Muslim and non-Muslim groups. These 19 studies generated six mechanisms that related the Islamic tradition, Muslim practices, and health inequities: (1) Interpretations of health and/or lack of health based on Islamic theology; (2) Ethical and/or cultural challenges within the clinical realm stemming from Islamic values or practices; (3) Perceived discrimination due to, or a lack of cultural accommodation of, religious values or practices in the clinical realm; (4) Health practices rooted within the Islamic tradition; (5) Patterns of health-care seeking based on Islamic values; and (6) Adverse health exposures due to having a Muslim identity.

CONCLUSION

While there is scant empirical research on Muslim health-care disparities, a preliminary conceptual model relating Islam to health inequities can be built from the extant literature. This model can serve to organize research on Muslim health and distinguish different ways in which a Muslim identity might contribute to the patterning of health disparities.

Health Benefits of Fasting and Caloric Restriction

PURPOSE OF REVIEW

Obesity and obesity-related diseases, largely resulting from urbanization and behavioral changes, are now of global importance. Energy restriction, though, is associated with health improvements and increased longevity. We review some important mechanisms related to calorie limitation aimed at controlling of metabolic diseases, particularly diabetes.

RECENT FINDINGS

Calorie restriction triggers a complex series of intricate events, including activation of cellular stress response elements, improved autophagy, modification of apoptosis, and alteration in hormonal balance. Intermittent fasting is not only more acceptable to patients, but it also prevents some of the adverse effects of chronic calorie restriction, especially malnutrition. There are many somatic and potentially psychologic benefits of fasting or intermittent calorie restriction. However, some behavioral modifications related to abstinence of binge eating following a fasting period are crucial in maintaining the desired favorable outcomes.

Does Lipid Profile Affect Thrombin Generation During Ramadan Fasting in Patients With Cardiovascular Risks?

There is evidence that diet and variation in lipid metabolism can influence blood coagulation, but little is known about the effect of Ramadan fasting on plasmatic coagulation pattern. We investigated the effect of Ramadan fasting on thrombin generation (TG) in patients with cardiovascular disease (CVD) risks, and we aimed to assess the effect of lipid profile on TG parameters. The study was conducted in 36 adults having at least 2 CVD risks and in 30 healthy controls. Coagulation pattern was assessed by both classical clotting times and TG test. A complete lipid profile was performed simultaneously. Patients were invited 2 times: 1 week before Ramadan and during the last week of the Ramadan. The TG parameters were not different in patients with CVD risks compared to healthy controls. Fasting had no effect on plasmatic coagulation parameters and on TG profile. Individual analysis of the mean rate index (MRI) of TG revealed 3 groups: group 1 with no modification of MRI, group 2 with a significant increase in MRI (81.64 nM/min vs 136.07 nM/min; P < .001), and group 3 with a significant decrease in MRI (125.27 nM/min vs 73.18 nM/min; P = .001). Only in group 2, a significant increase was observed in total cholesterol and low-density lipoprotein cholesterol. Changes in lipid profile during Ramadan fasting did not influence the global coagulation pattern in patients with CVD risks. Whereas, a significant increase in the propagation phase of TG was associated with a significant increase in cholesterol levels, which was not found with the other TG parameters.

Effect of Ramadan fasting on diabetes mellitus: a population-based study in Qatar

BACKGROUND

Over one billion Muslims fast worldwide during the month of Ramadan. Fasting during Ramadan is a radical change in lifestyle for the period of a lunar month, and it might affect the biochemical parameters among diabetic patients.

AIM

This study aimed to investigate the effect of Ramadan fasting on the blood levels of glucose, glycated hemoglobin (HbA1c), and lipid profile among diabetic patients observing fast during the Ramadan.

PATIENTS AND METHODS

An observational study recruiting 1301 Muslim diabetic patients above 18 years age was conducted in diabetic outpatient clinic of Hamad General Hospital, Hamad Medical Corporation, and Primary Health Care Center, Qatar, from July 2012 to September 2013. Data on sociodemographic characteristics (age, sex, nationality, marital status, education level, and occupation) and lifestyle habits (smoking and physical activity), blood pressures, and anthropometric measurements were obtained by a face-to-face interview and measurement using a structured questionnaire. Blood samples were collected for testing glucose, glycosylated hemoglobin (HbA1C), lipid profile, urea, and creatinine (by the licensed research assistants).

RESULTS

Slightly less than half of the participants were overweight (BMI: 25-29.9). Significantly higher proportion of female participants were obese as compared with male participants (P<0.001). Among both male participants and female participants, the average level of blood glucose, HbA1c, total cholesterol, low-density and high-density lipoprotein cholesterol, triglycerides, albumin, bilirubin, uric acid, and systolic and diastolic blood pressures were significantly lower during the Ramadan as compared with before Ramadan (P<0.001 each).

CONCLUSION

Results revealed that fasting during Ramadan is significantly associated with decrease in blood lipid profile, blood pressures, glucose, and HbA1C level among diabetic patients. Muslim diabetic patients after the consultation of their primary physician can fast during the month of Ramadan and it might be beneficial for their health.

Ramadan fasting is not usually associated with the risk of cardiovascular events: A systematic review and meta-analysis

Over one billion Muslims worldwide fast during the month of Ramadan. Ramadan fasting brings about some changes in the daily lives of practicing Muslims, especially in their diet and sleep patterns, which are associated with the risk of cardiovascular diseases. Over the years, many original studies have made the effort to identify the possible impact of the Ramadan fast on cardiovascular diseases. This systematic review and meta-analysis is an attempt to present the summary of key findings from those articles and an appraisal of selected literature. A systematic search using keywords of “;Ramadan fasting” and “;cardiovascular diseases” was conducted in primary research article and gray-literature repositories, in combination with hand searching and snow balling. Fifteen studies were finally selected for data extraction on the outcomes of stroke, myocardial infarction, and congestive heart failure. The analysis revealed that the incidence of cardiovascular events during the Ramadan fast was similar to the nonfasting period. Ramadan fast is not associated with any change in incidence of acute cardiovascular disease.

The cardiac patient in Ramadan

Ramadan is one of the five fundamental pillars of Islam. During this month, the majority of the 1.6 billion Muslims worldwide observe an absolute fast from dawn to sunset without any drink or food. Our review shows that the impact of fasting during Ramadan on patients with stable cardiac disease is minimal and does not lead to any increase in acute events. Most patients with the stable cardiac disease can fast safely. Most of the drug doses and their regimen are easily manageable during this month and may need not to be changed. Ramadan fasting is a healthy nonpharmacological means for improving cardiovascular risk factors. Most of the Muslims, who suffer from chronic diseases, insist on fasting Ramadan despite being exempted by religion. The Holy Quran specifically exempts the sick from fasting. This is particularly relevant if fasting worsens one's illness or delays recovery. Patients with unstable angina, recent myocardial infarction, uncontrolled hypertension, decompensated heart failure, recent cardiac intervention or cardiac surgery or any debilitating diseases should avoid fasting.

The effect of Ramadan fasting on cardiometabolic risk factors and anthropometrics parameters: A systematic review

Fasting during the month of Ramadan is a religious rituals of all healthy adult Muslims. However, there is no clear agreement on the effects of Ramadan fasting on cardiovascular disease. Comorbidities and factors such as age, gender, health status, daily duration of fasting, food intake before and after fasting may impact on a fasting individual’s cardiometabolic risk. This review was undertaken to assess the effects of Ramadan fasting on: the incidence of cardiovascular disease during the month of Ramadan; the clinical status of patients with stable cardiac disease; and any alterations in cardiometabolic risk profile.

Fasting during the month of Ramadan among patients with chronic kidney disease: renal and cardiovascular outcomes

Background

Fasting during the month of Ramadan is a religious obligation for Muslims who represent 20% of the world population. This study explores the safety of fasting for a whole month among patients with chronic kidney disease (CKD) with the possible risk of dehydration and hyperviscosity leading to deterioration of kidney functions and vascular thrombosis.

Methods

We followed CKD patients with stable kidney function who chose to fast during the month of Ramadan. A group of nonfasting CKD patients served as controls. Serum creatinine was recorded at the beginning of the month, after 1 week of fasting, at the end of the month and 3 months later. Patients were followed for major adverse cardiovascular events (MACE).

Results

A total of 131 CKD patients were recruited and included in two groups: fasting and nonfasting (mean baseline estimated glomerular filtration rate 27.7, SD 13 and 21.5, SD 11.8 mL/min/1.73 m², respectively). A rise of serum creatinine was noted during fasting in 60.4% of patients by Day 7 and was associated with intake of renin angiotensin aldosterone system antagonists [relative risk (RR) 2, P = 0.002]. Adverse cardiovascular events were observed in six patients in the fasting cohort and were associated with a rise of serum creatinine after 1 week of fasting (P = 0.009) and the presence of pre-existing cardiovascular disease (RR 15, P = 0.001); the latter association was confirmed by logistic regression analysis. Only one event was recorded in the nonfasting group, P = 0.036.

Conclusions

MACE occurred more frequently among fasting CKD patients with pre-existing cardiovascular disease and were predicted by an early rise of serum creatinine.

The cardiac patient during Ramadan and Hajj

The holy month of Ramadan is one of the five pillars of Islam. During this month, fasting Muslims refrain from eating, drinking, smoking, and sex from dawn until sunset. Although the Quran exempts sick people from the duty of fasting, it is not uncommon for many heart disease patients to fast during Ramadan. Despite the fact that more than a billion Muslims worldwide fast during Ramadan, there is no clear consensus on its effects on cardiac disease. Some studies have shown that the effects of fasting on stable patients with cardiac disease are minimal and the majority of patients with stable cardiac illness can endure Ramadan fasting with no clinical deterioration. Fasting during Ramadan does not seem to increase hospitalizations for congestive heart failure. However, patients with decompensated heart failure or those requiring large doses of diuretics are strongly advised not to fast, particularly when Ramadan falls in summer. Patients with controlled hypertension can safely fast. However, patients with resistant hypertension should be advised not to fast until their blood pressure is reasonably controlled. Patients with recent myocardial infarction, unstable angina, recent cardiac intervention or cardiac surgery should avoid fasting. Physician advice should be individualized and patients are encouraged to seek medical advice before fasting in order to adjust their medications, if required. The performance of the Hajj pilgrimage is another pillar of Islam and is obligatory once in the lifetime for all adult Muslims who are in good health and can afford to undertake the journey. Hajj is a physically, mentally, emotionally, and spiritually demanding experience. Medical checkups one or two months before leaving for Hajj is warranted, especially for those with chronic illnesses such as cardiovascular disease. Patients with heart failure, uncontrolled hypertension, serious arrhythmias, unstable angina, recent myocardial infarction, or cardiac surgery should be considered unfit for undertaking the Hajj pilgrimage.

Religion and disparities: considering the influences of Islam on the health of American Muslims

Both theory and data suggest that religions shape the way individuals interpret and seek help for their illnesses. Yet, health disparities research has rarely examined the influence of a shared religion on the health of individuals from distinct minority communities. In this paper, we focus on Islam and American Muslims to outline the ways in which a shared religion may impact the health of a racially, ethnically, and socioeconomically diverse minority community. We use Kleinman's "cultural construction of clinical reality" as a theoretical framework to interpret the extant literature on American Muslim health. We then propose a research agenda that would extend current disparities research to include measures of religiosity, particularly among populations that share a minority religious affiliation. The research we propose would provide a fuller understanding of the relationships between religion and health among Muslim Americans and other minority communities and would thereby undergird efforts to reduce unwarranted health disparities.

Impact of religious Ramadan fasting on cardiovascular disease: a systematic review of the literature

BACKGROUND

Fasting during the month of Ramadan is a religious obligation that is practiced by millions of people around the world yet there is no clear scientific consensus on its effects on cardiovascular disease. This study was performed to inform physicians as well as patients of evidence based recommendations on this subject.

AIM

The study was undertaken to assess: (1) any alteration in the incidence of acute cardiac illness during Ramadan fasting; (2) whether fasting during the month of Ramadan alters the clinical status of patients with stable cardiac disease; and (3) the impact of Ramadan fasting on cardiovascular risk factors in normal subjects, in patients with stable cardiac disease, metabolic syndrome, dyslipidemia, type 2 diabetes and systemic hypertension.

STUDY DESIGN

Systematic review of the literature.

METHOD

A Medline search of the English literature published between January 1980 and September 2012.

RESULTS

The incidence of acute cardiac illness during Ramadan fasting was similar to non-fasting days, although the timing of symptom onset may be different, with significant increase in events during the period of 'breaking fast' when compared to non-fasting days. The majority of patients with stable cardiac illness can undergo Ramadan fasting without any clinical deterioration. Body mass index, lipid profile, and blood pressure showed significant improvement in normal healthy subjects, patients with stable cardiac illness, metabolic syndrome, dyslipidemia and hypertension during Ramadan fasting. The lipid profile of diabetic patients deteriorated significantly during Ramadan fasting.

CONCLUSIONS

Ramadan fasting is not associated with any change in incidence of acute cardiac illness and the majority of cardiac patients can fast without any difficulty. Improvement in lipid profile, especially 30% to 40% increment in high-density lipoprotein, as reported in some studies, appear promising. Diabetic patients should be carefully monitored during Ramadan fasting.

The impact of diurnal fasting during Ramadan on the lipid profile, hs-CRP, and serum leptin in stable cardiac patients

AIM

To study the effect of strict prolonged fasting on lipid profile, serum leptin, and high- sensitivity C-reactive protein (hs-CRP) in patients with different stable cardiac illnesses and look for associated new cardiac events and any correlation between entire variables.

METHODS

A total of 56 patients of different stable cardiac illnesses were followed in our cardiology outpatient for 3 months. Data concerning their ability to fast were collected: New York Heart Association class of congestive cardiac failure, angina class, previous myocardial infarction, previous coronary artery bypass graft, percutaneous coronary intervention, severity of valvular lesion, metallic prosthetic valve, and traditional risk factors (diabetes mellitus, insulin requirement, hypertension, hypercholesterolemia, smoking habit, and obesity). Detailed clinical examination and electrocardiography were performed in all patients in three consecutive visits before, during, and after Ramadan. Echocardiographic and angiographic findings and medication plans were collected from patient records. Lipid profile, serum leptin, and hs-CRP were assessed before, during, and after Ramadan.

RESULTS

All patients fasted during Ramadan: 80.4% were male, 67.9% were aged >50 years, 71.4% had no change in their symptoms during fasting while 28.6% felt better. No patient has deteriorated. 91.1% of the patients were compliant with medicine during Ramadan, 73.2% after. 89.3% were compliant with diet during Ramadan with no significant change in body weight in the follow-up period. No cardiac or noncardiac morbidity or mortality was reported. High- density lipoprotein-cholesterol (HDL-C) decreased significantly during compared to before fasting (P = 0.012). Low-density lipoprotein-cholesterol (LDL-C) significantly increased during compared to before fasting (P = 0.022). No statistically significant changes were observed in total cholesterol (TC), triglycerides (TG), serum leptin, or hs-CRP. Significant correlation was observed between TC and hs-CRP during fasting (P = 0.036), but not with TG, LDL-C, or HDL-C (P > 0.05). Neither of these correlated with serum leptin (P > 0.05), but significant correlation was observed between hs-CRP and serum leptin (P < 0.05).

CONCLUSION

Ramadan fasting in stable cardiac patients has no effect on their clinical status, serum leptin, or hs-CRP, but results in decrease in HDL-C, increase in LDL-C, with significant correlation between TC and hs-CRP during Ramadan, but not with TG, LDL-C, or HDL-C, and with significant correlation between hs-CRP and serum leptin before, during, and after fasting.

Health is a spiritual thing: perspectives of health care professionals and female Somali and Bangladeshi women on the health impacts of fasting during Ramadan

OBJECTIVE

To explore perspectives of health care professionals and female Somali and Bangladeshi Muslim women on practices related to fasting during Ramadan, the impact of fasting on health and the role of health professionals during Ramadan.

DESIGN

A cross-sectional qualitative study was conducted. Two culturally specific focus groups were conducted with six Somali and seven Bangladeshi Muslim women who observed Ramadan and lived in an inner-city neighbourhood of Toronto, Canada. Individual semi-structured interviews were conducted with 22 health care professionals practicing in this inner-city area (three of whom were Muslim). Data were analysed using thematic qualitative analysis.

RESULTS

Both Muslim women and health care professionals recognised the spiritual significance of the Ramadan fast. Muslim participants considered the fast to be beneficial to health overall, whereas health care professionals tended to reflect on health concerns from fasting. Many health care professionals were not fully aware of fasting practices during Ramadan and some found it challenging to counsel patients about the health effects of fasting. Muslim women expressed disagreement regarding which medical interventions were permitted during fasting. They generally agreed that health care professionals should not specifically advise against fasting, but instead provide guidance on health maintenance while fasting. Both groups agreed that guidelines developed by the health care and faith communities together would be useful.

CONCLUSION

There are a variety of health beliefs and observances among female Muslim Somali and Bangladeshi women and a range of knowledge, experience and opinions among health care professionals related to fasting during Ramadan and health. Overall, there is a need for improved communication between members of the Muslim community and health professionals in Canada about health issues related to fasting during Ramadan. Strategies could include published practice guidelines endorsed by the Muslim community; patient education materials developed in collaboration with health and religious experts; or further qualitative research to help professionals understand the beliefs and observances of Muslim people.

Beneficial effects of mild stress (hormetic effects): dietary restriction and health

Hormesis is defined as a dose-response phenomenon characterized by low-dose stimulation and high-dose inhibition, and has been recognized as representing an overcompensation for mild environmental stress. The beneficial effects of mild stress on aging and longevity have been studied for many years. In experimental animals, mild dietary stress (dietary restriction, DR) without malnutrition delays most age-related physiological changes, and extends maximum and average lifespan. Animal studies have also demonstrated that DR can prevent or lessen the severity of cancer, stroke, coronary heart disease, autoimmune disease, allergy, Parkinson's disease and Alzheimer's disease. The effects of DR are considered to result from hormetic mechanisms. These effects were reported by means of various DR regimens, such as caloric restriction, total-nutrient restriction, alternate-day fasting, and short-term fasting. Mild dietary stress, including restriction of amount or frequency of intake, is the essence of DR. For more than 99% of their history, humans lived as hunter-gatherers and adapted to restrictions in their food supply. On the other hand, an oversufficiency of food for many today has resulted in the current global epidemic of obesity and obesity-related diseases. DR may be used, therefore, as a novel approach for therapeutic intervention in several diseases, when detailed information about effects of mild dietary stress on human health is obtained from clinical trials.

Diabetes and fasting during Ramadan

Abstinence from food and liquid during daylight hours is observed by Muslim individuals during the month of Ramadan. Even though the Koran exempts the sick from fasting, many people with diabetes still fast during this religious period. It is essential for patients, family and healthcare professionals to be aware of the religious attitude to and health implications of fasting. Major changes in dietary habits, daily physical activities and sleeping patterns during Ramadan have significant impact on the glycaemic control, lipid profile, weight and dietary intake. Hence, the patient is encouraged to have appropriate pre-Ramadan assessment and education in order to stratify and modify his or her risk with fasting. Dose and timing adjustments to insulin and to some oral hypoglycaemic agents, especially sulphonylureas, may well be necessary during Ramadan.

Circadian rhythm of stroke onset during the month of Ramadan

BACKGROUND AND PURPOSE

The onset of acute stroke exhibits a circadian pattern occurring more frequently in late morning hours. The objective of this study was to investigate the diurnal pattern of stroke during the month of Ramadan.

PATIENTS AND METHODS

We studied consecutive stroke patients 1 month before Ramadan (BR) and during Ramadan (DR) over two successive years 2007 and 2008. The age, gender, risk factor profiles were analyzed. The National Institute of Health and Stroke Scale Score (NIHSS) was used for clinical assessment at admission. The exact time of stroke onset in both groups was obtained.

RESULTS

A total of 507 patients were studied: 245 patients in the DR group and 262 patients in the BR group. The age distribution of patients was not significantly different between the two groups. There was no statistically significant difference in the sex ratio, risk factors, and NIHSS score between the two groups (P > 0.05). The higher frequency of stroke onset time in the BR group was in the time between 6:00 a.m. and noon; whereas the frequency was higher between noon and 6:00 p.m. in the DR group.

CONCLUSION

A significant shift of the circadian pattern of stroke onset time from the period between 6:00 a.m. and noon to that between noon and 6:00 pm has been found during the month of Ramadan.

Religious observance and acute coronary syndrome in predominantly Muslim Albania: a population-based case-control study in Tirana

PURPOSE

We aimed to assess the association of religious observance with acute coronary syndrome (ACS) in a predominantly Muslim population.

METHODS

A case-control study conducted in Tirana, Albania in 2003-2006 included 467 nonfatal consecutive ACS patients (370 men, 97 women; 88% response) and a population-based control group (469 men, 268 women; 69% response). Religious observance was assessed as a composite score based on mosque/church attendance, frequency of prayer and ritual fasting. The association of religiosity with ACS was assessed by multivariable-adjusted logistic regression.

RESULTS

Nonobservance was frequent in this population (67% among Muslim controls, 55% in Christian controls). Religious observance was inversely associated with ACS in both groups (multivariable-adjusted odds ratios for above median observance scores vs zero observance: 0.45 [95% confidence interval (CI) = 0.26-0.77] in Muslims, 0.58 [0.25-1.31] in Christians, and 0.48 [0.31-0.74] overall]. Associations with ACS were strongest for prayer and fasting.

CONCLUSIONS

In a country experiencing major socioeconomic transition from rigid communism, including extreme state-enforced secularism, we found an apparent protective effect associated with religious observance in both Muslims and Christians. This may be the first such study reported in a Muslim population.

Prevalence and Impact of Diabetes Mellitus in Patients With Acute Myocardial Infarction: A 10-year Experience

Background: Diabetes mellitus is associated with a higher incidence of acute myocardial infarction. Objective: To study the prevalence and outcome of patients with diabetes among patients with acute myocardial infarction. Methods: Retrospectively, patients who presented with acute myocardial infarction in a 10-year period were identified from the coronary care unit database. Results: A total of 1598 Qatari patients were admitted with acute myocardial infarction, 863 (54%) of them had diabetes mellitus (females 68.5% vs males 48.3%; P < .001). In-hospital mortality rate was non-significantly higher in diabetic patients (18% vs 15% P = .15). Aspirin (odds ratio 2.39, 95% confidence interval 1.96-2.90, P = .003] and β-blocker use (odds ratio 1.75, 95% CI 1.21-2.52, P = .0001) were independently associated with reduced mortality risk. Conclusions: The prevalence of diabetes mellitus among patients with acute myocardial infarction in a geographically defined population in the developing world is high with a trend for poor outcomes. However, mortality was not significantly higher in diabetes mellitus than non-diabetes mellitus patients.

Ramadan and eyedrops: the muslim perspective

PURPOSE

To assess views of Muslims with regard to the use of eyedrops during fasting periods of Ramadan and to determine if demographic, religious, and educational factors or the perceived severity of an ocular condition influence these views.

DESIGN

Cross-sectional survey.

PARTICIPANTS

Two hundred adult Muslims.

METHODS

A questionnaire-based survey.

MAIN OUTCOME MEASURES

The main outcome measures studied were the proportion of respondents who believe that the use of eyedrops during fasting hours of Ramadan would break the fast and the proportion of respondents who would use drops during fasting hours of Ramadan.

RESULTS

Of the 200 questionnaires collected, 10 were excluded because of incomplete data entry (n = 190). Among respondents, 63.7% (n = 121) believe that using eyedrops during fasting periods of Ramadan would break the fast, and only 34.2% (n = 65) would use drops during this period. A further 34.2% (n = 65) would continue their regular treatment, 35.8% (n = 68) would use drops for a nonpainful eye condition, 66.8% (n = 127) for a painful eye condition, 35.3% (n = 67) for a condition that did not affect vision, and 75.8% (n = 144) would use drops during the fasting period for an eye condition if vision was affected. No significant association was noted when comparing views of respondents based on gender, occupation, education, and number of days the fast is observed. Statistical significance was reached when comparing the views of Muslims who would fast additional days if a fast was broken compared with those who would not (P<0.001).

CONCLUSIONS

Ramadan could be an important cause for noncompliance with prescribed ophthalmic treatment. This study provides an insight into views of Muslims regarding use of eyedrops during Ramadan. The results suggest that extensive misuse of prescribed drops should be anticipated during Ramadan.