Impact of Ramadan Fasting on Dietary Intakes Among Healthy Adults: A Year-Round Comparative Study

Shifts in food consumption patterns in the Levant: a systematic review of the last six decades

BACKGROUND

Food consumption patterns have changed tremendously since the mid-twentieth century, with a rapid global nutritional shift raising concerns, particularly in disadvantaged regions such as the Eastern Mediterranean region (EMR). Given that food intake is very context-specific, this research examines food consumption patterns in Jordan, Lebanon, Palestine, and Syria, representing the contemporary Levant region.

METHODS

A systematic review was conducted by searching PubMed, EMBASE, Web of Science, and CINAHL. The eligibility criteria were to include only original peer-reviewed observational studies reporting individual-level food consumption among local Jordanians, Lebanese, Palestinians, and Syrians. Extracted data were synthesized through descriptive statistics and presented in tables and charts. The risk of bias was assessed using the tool developed by Hoy et al. for prevalence studies.

RESULTS

A total of 43 articles that measured and reported food consumption at the individual level for the populations in these countries were included. Findings reveal that in the 1960s, diets in the region were primarily local, seasonal, and plant-based, with moderate to low animal product intake. By the 1990s, a noticeable shift occurred, marked by increased consumption of processed foods, refined carbohydrates, and animal products, with minimal increase in fruit and vegetable intake. Most studies were conducted in Lebanon, limiting the generalizability of findings across the Levant countries.

CONCLUSION

This review presents an understanding of food consumption changes on the level of food items, food groups, and dietary patterns specific to the Levant. Future studies on food consumption patterns should prioritize national surveys using valid, reliable, and cultural-specific measurement tools and provide detailed, age-disaggregated dietary data. Public health interventions are needed to address the ongoing dietary shift, which is unfolding amid political instability, economic crises, and food insecurity.

The effect of Ramadan fasting on anthropometric and body composition of healthy adults within different time points: A systematic review and meta-analysis

To date, the effect of Ramadan fasting (RF) on anthropometric and body compositions remains inconsistent. This review aimed to investigate the impact of RF on anthropometric and body composition of healthy adults within different time points during and after RF. Qualified studies from MEDLINE, Web of Science, Embase, CINAHL Complete, ProQuest, and Scopus were included. We involved prospective observational studies with pre- and post-test design. The anthropometric and body composition parameters consist of weight, BMI, waist circumference (WC), hip circumference (HC), waist-to-hip ratio (WHR), absolute fat mass (FM), fat percentage (FP), fat-free mass (FFM), and total body water (TBW). Fifty-four studies involving 2857 subjects were identified and conducted in 21 countries between 1987 and 2024. RF exerts a significant reduction in weight and BMI, starting within the second and third week of RF, peaking in the first week after RF, and gradually returning to the pre-Ramadan value in the weeks afterward. Meanwhile, WC, HC, and WHR were significantly alleviated within the last week of RF and the first week post-RF for HC. In body composition, RF elicits a significant but small reduction of absolute FM and FP within the third and fourth week of RF, while FFM and TBW were not affected. During Ramadan, anthropometric and body composition changes are transient and elicit only a short-term effect. Such leverages need to be maintained to achieve a long-term benefit of RF on the anthropometric and body composition of healthy adults.

Cardiometabolic and obesity risk outcomes of dawn-to-dusk, dry intermittent fasting: Insights from an umbrella review

BACKGROUND & AIMS

This umbrella review comprehensively and systematically summarizes meta-analyses on the impact of dawn-to-dusk, dry intermittent fasting of Ramadan (RIF) on cardiometabolic and glucose homeostasis indicators.

METHODS

Twenty meta-analyses were examined on the effects of RIF on body fat percentage (BFP), fat mass, fat-free mass, body mass index (BMI), body weight (BW), waist circumference (WC), systolic and diastolic blood pressure (SBP, DBP), high-density lipoprotein cholesterol (HDL-C), low-density lipoprotein cholesterol (LDL-C), total cholesterol (TC), triglycerides (TG), and very low-density lipoprotein cholesterol (VLDL-C), fasting blood glucose (FBG), glycated hemoglobin (HbA1c), insulin resistance (HOMA-IR), serum insulin, leptin, and adiponectin. Results of continuous outcomes were pooled from included meta-analyses. We employed random-effects meta-analysis using the restricted maximum likelihood method to estimate heterogeneity. P-values were derived from standard meta-analytic tests, including Egger's test for small-study effects and the excess significance test for potential publication bias. Additionally, we applied criteria from Ioannidis' evidence classification to assess the credibility of the findings.

RESULTS

In healthy subjects, RIF was associated with significant reductions in BW (Hedges' G = -0.33; 95 % confidence interval (CI) = -0.37, -0.29; p-value = 2.63 × 10-52), WC (Hedges' G = -0.30; 95 % CI = -0.38, -0.23; p-value = 5.73 × 10-15), BFP (Hedges' G = -0.26; 95 % CI = -0.37, -0.14; p-value = 6.81 × 10-06), DBP (n = 3,456; Hedges' G = -0.26; 95 % CI = -0.38, -0.15; p-value = 9.18 × 10-06), TC (n = 9,314; Hedges' G = -0.16; 95 % CI = -0.25, -0.07; p-value = 6.27 × 10-04), and TG levels (n = 9,020; Hedges' G = -0.16; 95 % CI = -0.24, -0.08; p-value = 6.87 × 10-05). Moreover, in general population, TG (n = 16,688; Hedges' G = -0.15; 95 % CI = -0.22, -0.08; p-value <0.01) and FBG (n = 16,106; Hedges' G = -0.23; 95 % CI = -0.33, -0.13; p-value <0.01) were significantly reduced.

CONCLUSIONS

Dawn-to-dusk, dry RIF shows promise as a complementary therapy and preventive measure for reducing cardiometabolic and obesity-related risks. However, controlled studies are necessary to validate its effectiveness and fully understand its health implications.

Dawn-to-dusk intermittent fasting is associated with overexpression of autophagy genes: A prospective study on overweight and obese cohort

AIM AND BACKGROUND

A growing body of evidence supports the impact of intermittent fasting (IF) on longevity and healthy aging via the modulation of autophagy genes. The activation of the catabolic autophagic machinery (LAMP2, LC3B, ATG5, and ATG4D) has protective effects against degenerative aging and chronic diseases. This research examined the changes in the expression of the aforementioned genes upon the observance of dawn-to-dusk IF among metabolically healthy participants with overweight and obesity.

METHODS

Fifty-one (51) participants (36 males and 15 females, 38.84 ± 11.73 years) with overweight and obesity (BMI = 29.75 ± 5.04 kg/m2) were recruited and monitored before and at the end of the commencement of the four-week IF. Six healthy subjects with normal BMI (21.4 ± 2.20 kg/m2) were recruited only to standardize the reference for normal levels of gene expressions. At the two time points, anthropometric, biochemical, and dietary assessments were performed, and LAMP2, LC3B, ATG5, and ATG4D gene expressions were assessed using qRT-PCR on RNA extracted from whole blood samples.

RESULTS

At the end of IF, and compared to the pre-fasting levels, the relative gene expressions among participants with overweight/obesity were significantly increased for the three autophagy genes LAMP2, LC3B, and ATG5, with increments of about 4.2 folds, 1.9-fold, and 1.4-fold, respectively. In contrast, the increase in the ATG4D gene was not significant. Concomitantly, significant decreases were found in body weight, BMI, fat mass, body fat percent, hip and waist circumferences, LDL, IL-6, and TNF-a (P < 0.05), While HDL, IL-10, and CD163 significantly increased (P < 0.05). Binary logistic regression analysis for genetic expressions showed no significant association between high-energy intake, waist circumference, or obesity and the four gene expressions.

CONCLUSIONS

Four consecutive weeks of dawn-to-dusk IF of Ramadan is associated with the upregulation of autophagy gene expressions in participants with overweight/obesity, and this may explain, at least in part, its favorable short-term temporal metabolic and health-improving effects on early aging-related markers. Hence, IF presumably may entail a protective impact against early markers of aging and metabolic diseases in participants with overweight/obesity.

The effect of Ramadan intermittent fasting on anthropometric, hormonal, metabolic, inflammatory, and oxidative stress markers in pre-and post-menopausal women: a prospective cohort of Saudi women

Background

The menopausal transition significantly affects cardiometabolic health, primarily due to changes in reproductive hormones, particularly decreased estrogen levels and relative androgen excess. Adult Muslim women, both pre-and post-menopausal, are mandated to observe Ramadan intermittent fasting (RIF) every year. Therefore, the current study was designed to investigate RIF's effects on pre-menopausal (PRE-M) and post-menopausal (POST-M) healthy women's cardiometabolic health markers. This study further evaluated the relationship between tested markers and the participant's basic variables, such as BMI and body fatness. Due to differences in physiological and metabolic biomarkers between groups, RIF is likely to impact PRE-M and POST-M women differently.

Methods

This study included 62 healthy women (31 PRE-M, aged 21-42 years, and 31 POST-M, aged 43-68 years) who observed RIF. Anthropometrics, sex hormones, lipid profile, pro-inflammatory (TNF-α), anti-inflammatory (IL-10) cytokines, the oxidative stress markers malondialdehyde (MDA), total antioxidant capacity (TAC), superoxide dismutase (SOD), glutathione peroxidase (GPx), and aging biomarker insulin-like growth factor-1 (IGF-1); all were tested 1 week before and at the fourth week of Ramadan.

Results

Body weight, BMI, waist circumference, body fat percentage (BFP), fat mass, fat mass index, triglycerides, and diastolic blood pressure significantly (p < 0.05) decreased at the end of Ramadan in both groups in comparison to the pre-fasting period. Contrarily, HDL, SOD, GPx, and IL-10 significantly (p < 0.05) increased in both groups. Estrogen levels significantly (p < 0.05) decreased in PRE-M women, whereas significantly (p < 0.05) increased in POST-M women. The progesterone levels, TAC, MDA, and IGF-1 remained unchanged in both groups. TNF-α significantly decreased in both groups, but the magnitude of reduction was higher in PRE-M women. Sex hormones and some metabolic biomarkers, especially in POST-M women, variably exhibited positive or negative relationships to BMI and BFP. RIF may influence the levels of estrogen, TNF-α, and IL-10 through improvements in metabolic health, reductions in body fat, activation of autophagy, modulation of immune responses, and changes in hormonal regulation.

Conclusion

The RIF was generally associated with improved anthropometric, metabolic, inflammatory, and oxidative stress markers in both PRE-M and POST-M healthy women. Adhering to healthy dietary and lifestyle guidelines by pre-and post-menopausal women during Ramadan may foster the health benefits gained.

Ramadan during pregnancy and offspring health outcomes over the life course: a systematic review and meta-analysis

BACKGROUND

Intermittent fasting, such as during Ramadan, is prevalent among pregnant women. However, the association between Ramadan during pregnancy and offspring health along the life course has not been fully established.

OBJECTIVE AND RATIONALE

Fetal programming research indicates that prenatal exposures, particularly during early pregnancy, can cause long-term structural and physiological changes that adversely affect offspring health. Our objective was to systematically identify and assess the evidence regarding Ramadan during pregnancy.

SEARCH METHODS

A total of 31 studies were sourced from PubMed, EMBASE, Web of Science, and EconLit. Included studies evaluated outcomes in individuals with prenatal Ramadan exposure, compared to unexposed Muslim controls. Main outcomes were birth weight, gestational length, and sex ratio in newborns; height, mortality, and cognition in children; and disabilities, chronic diseases, and human capital accumulation in adults. Each study was evaluated for risk of bias. The overall quality of evidence was appraised using the GRADE system. Random-effects meta-analyses were conducted for outcomes analyzed in at least three primary studies.

OUTCOMES

The initial search identified 2933 articles, 1208 duplicates were deleted. There were 31 publications fulfilled the eligibility criteria for the qualitative synthesis; 22 studies were included in meta-analyses. The overall quality of the evidence was low to moderate and differed by study design and outcome. Among newborns, prenatal Ramadan exposure was not associated with birth weight (mean difference (MD) -3 g (95% CI -18 to 11; I2 = 70%) or the likelihood of prematurity (percentage point difference (PPD) 0.19 (95% CI -0.11 to 0.49; I2 = 0%)). The probability that the newborn is male was reduced (PPD -0.14 (95% CI -0.28 to -0.00; I2 = 0%)). This potentially reflects sex-specific mortality rates resulting from adverse in utero circumstances. In childhood, the exposed performed slightly poorer on cognitive tests (MD -3.10% of a standard deviation (95% CI -4.61 to -1.58; I2 = 51%)). Height among the exposed was reduced, and this pattern was already visible at ages below 5 years (height-for-age z-score MD -0.03 (95% CI -0.06 to -0.00; I2 = 76%)). A qualitative literature synthesis revealed that childhood mortality rates were increased in low-income contexts. In adulthood, the prenatally exposed had an increased likelihood of hearing disabilities (odds ratio 1.26 (95% CI 1.09 to 1.45; I2 = 32%)), while sight was not affected. Other impaired outcomes included chronic diseases or their symptoms, and indicators of human capital accumulation such as home ownership (qualitative literature synthesis). The first trimester emerged as a sensitive period for long-term impacts.

WIDER IMPLICATIONS

Despite the need for more high-quality studies to improve the certainty of the evidence, the synthesis of existing research demonstrates that Ramadan during pregnancy is associated with adverse offspring health effects in childhood and especially adulthood, despite an absence of observable effects at birth. Not all health effects may apply to all Muslim communities, which are diverse in backgrounds and behaviors. Notably, moderating factors like daytime activity levels and dietary habits outside fasting hours have hardly been considered. It is imperative for future research to address these aspects.

REGISTRATION NUMBER

PROSPERO (CRD42022325770).

Changes in energy and macronutrient intakes during Ramadan fasting: a systematic review, meta-analysis, and meta-regression

CONTEXT

Ramadan fasting (RF) is associated with various physiological and metabolic changes among fasting Muslims. However, it remains unclear whether these effects are attributable to changes in meal timing or changes in dietary energy and macronutrient intakes. Furthermore, the literature on the associations between RF, meal timing, and energy and macronutrient intakes is inconclusive.

OBJECTIVES

This systematic review aimed to estimate the effect sizes of RF on energy and macronutrient intakes (carbohydrates, protein, fats, dietary fiber, and water) and determine the effect of different moderators on the examined outcomes.

DATA SOURCES

The Cochrane, CINAHL, EMBASE, EBSCOhost, Google Scholar, PubMed/MEDLINE, ProQuest Medical, Scopus, ScienceDirect, and Web of Science databases were searched from inception to January 31, 2022.

DATA EXTRACTION

The studies that assessed energy, carbohydrate, protein, fat, fiber, and water intakes pre- and post-fasting were extracted.

DATA ANALYSIS

Of the 4776 identified studies, 85 relevant studies (n = 4594 participants aged 9-85 y) were selected. The effect sizes for the studied variables were as follows: energy (number of studies [K] = 80, n = 3343 participants; mean difference [MD]: -142.45; 95% confidence interval [CI]: -215.19, -69.71), carbohydrates (K = 75, n = 3111; MD: -23.90; 95% CI: -36.42, -11.38), protein (K = 74, n = 3108; MD: -4.21; 95% CI: -7.34, -1.07), fats (K = 73, n = 3058; MD: -2.03; 95% CI: -5.73, 1.67), fiber (K = 16, n = 1198; MD: 0.47; 95% CI: -1.44, 2.39), and water (K = 17, n = 772; MD: -350.80; 95% CI: -618.09, 83.50). Subgroup analyses showed age significantly moderated the 6 dietary outcomes, and physical activity significantly moderated water intake. There were significant reductions in energy, carbohydrate, and protein intakes during RF.

CONCLUSIONS

The change in meal timing rather than quantitative dietary intake may explain various physiological and health effects associated with RF.

Incorporating Halal Into Healthy and Equitable Dietary Patterns to Address Food and Nutrition Security Among K-12 and University Students: A Perspective

Food and nutrition insecurity exist at an alarming rate in the US educational system, ranging from 17% among K-12 students up to 58.8% among university students. Many Muslim American students face food and nutrition insecurity due, in part, to a lack of acknowledgment of student adherence to halal dietary guidelines and the availability of certified halal options at school. This has implications for health, learning, and social outcomes. In this perspective paper, we provide short-term, mid-term, and long-term recommendations to address food and nutrition insecurity among halal-observant students to advance healthy dietary patterns.

Changes in sleep, physical activity, and health behaviors among Nigerian fasting adults in Ramadan during the COVID-19 pandemic

BACKGROUND

There is limited data on sleep, physical activity, and health-related behaviors among the general public during Ramadan, particularly during the COVID-19 pandemic. This study aimed to assess the factors associated with sleep and physical activity changes among Nigerian Muslims during Ramadan fasting.

MATERIALS AND METHODS

A nationwide web-based cross-sectional study was conducted among Nigerians aged ≥18 years who performed diurnal fasting during Ramadan. The target sample size was obtained using Fisher's formula, and snowball sampling was employed. Adapted versions of the International Physical Activity Questionnaire Short Form and Copenhagen Psychosocial Questionnaire II were used to evaluate sleep and physical activity. Correlates of change in physical activity and sleep quality were assessed using logistic regression analysis.

RESULTS

Seven hundred and seventy individuals participated in the study. During Ramadan, 39.1% (95% confidence interval (CI): 35.6%-42.6%) reported decreased physical activity, and 56.6% (95% CI; 53.0%-60.2%) stated having self-reported good sleep. The independent correlates of physical activity were female sex (adjusted odds ratio (aOR):0.5, 95% CI: 0.4-0.8), having very good sleep (aOR: 0.4, 95% CI: 0.2-0.7), and obesity (aOR: 2.0, 95% CI: 1.1-3.7). In addition, factors associated with improved self-reported sleep quality were perceived good health state (aOR: 8.8, 95% CI: 1.1-72.4), sleeping 7-9 h per day (aOR: 5.5, 95% CI: 2.6-10.3), and sleeping for over 9 h per day (aOR: 4.6, 95% CI: 2.1-14.1).

CONCLUSIONS

Although physical activity decreased by about a third, over half of the respondents lost weight and slept well during Ramadan. Strategies to include intermittent fasting in positive lifestyle changes could improve the health and well-being of the population.

Annual and Seasonal Patterns of Dietary Intake in Australian Adults: A Prospective Cohort Study

Poor diet is a major risk factor for non-communicable disease. The aims of this study were to describe temporal patterns and seasonal changes in diet across the year in Australian adults. A total of 375 adults from a prospective cohort study conducted between 1 December 2019 and 31 December 2021 in Adelaide, Australia, were asked to complete the Dietary Questionnaire for Epidemiological Studies at eight timepoints over a year. Average intakes over the previous month of total energy, macronutrients, healthy food groups, and discretionary foods and beverages were derived. Temporal patterns in diet were analysed descriptively. Multilevel linear regression modelling was used to assess seasonal differences in diet. Of the 375 participants recruited, 358 provided sufficient data for analysis. Intake of total energy, all macronutrients, and most discretionary foods and beverages peaked in December. Total energy intake was higher in summer than in autumn, winter, and spring. Fruit intake was higher in summer than in winter. Consumption of alcoholic beverages was higher in summer than in autumn, winter, and spring. Consumption of non-alcoholic beverages was higher in summer than in autumn and winter. This study identified temporal differences in dietary intake among Australian adults. Seasonal effects appear to be driven largely by increases in consumption of foods and beverages over the December (summer) holiday period. These findings can inform the design and timing of dietary interventions.

Effects of Ramadan Fasting on Sleep and Physical Fitness among Young Female Handball Players

OBJECTIVES

This study examines the potential impact of Ramadan fasting on sleep patterns and physical fitness in under 14 (U14) and under 17 (U17) female handball players.

METHODS

For this study, sixty-five female handball players' (U14, n = 33 and U17, n = 32) sleep habits were assessed before (BR) and during the first (R1) and last weeks (R4) of Ramadan using: the Pittsburgh Sleep Quality Index (PSQI), the Insomnia Severity Index (ISI), and the Epworth Sleepiness Scale (ESS). Physical ability tests including balance and jumps were conducted throughout these periods.; Results: During Ramadan, both groups noted significant increases in PSQI and ISI scores during R1 (p < 0.01 and p < 0.05, respectively) and R4 (p < 0.05 and p < 0.05, respectively) compared to before Ramadan (BR). For the U14 group, a significant increase occurred in ESS scores during R1 (p < 0.01) and R4 (p < 0.05), whereas for the U17 group, this increase was limited over the R1 period (p < 0.05). In contrast, for all physical ability parameters, both groups showed no significant difference during R1 and R4; Conclusions: During adolescence, Ramadan fasting may alter sleep patterns in young female athletes but appears to have no effect on their performance in short-duration exercises.

The dietary changes during Ramadan and their impact on anthropometry, blood pressure, and metabolic profile

Background

The effect of Ramadan intermittent fasting (RIF) on the metabolic profile, anthropometry and blood pressure has been investigated in multiple studies. However, it is still unknown to what extent changes in nutrient intakes contribute to these changes.

Methods

This observational study was conducted in London (UK) in 2019. The study collected diverse data from a community-based sample in London before and during/after Ramadan. Collected data included a 3-day food diary (before and during Ramadan), as well as blood samples, anthropometric measurements and blood pressure (before and after Ramadan). The food diary was translated into nutritional data using nutrition software "Nutritics." The changes in nutrient intakes were investigated using a mixed-effects regression model. The impact of adjusting for nutrient intake change was investigated on the absolute difference of metabolites (Nightingale platform), systolic/diastolic blood pressure and anthropometric measures.

Results

The study collected data on food intake before and during Ramadan from 56 participants; the mean age was 44.7 ± 17.3, and 51.8% (n = 29) were females. We found a change in the intake of 11 nutritional factors, glucose, fructose, betaine, sugars, sugars as monosaccharide equivalents, lutein/zeaxanthin, starch, starch as monosaccharide equivalents, proline, glutamic acid and lycopene. No changes in quantities or proportions of macronutrients, carbohydrates, protein and fat. Mainly, the changes in diet during Ramadan are characterized by more consumption of sugars (62%, p < 0.001) and a lower intake of starch (-21%, p = 0.012). The changes in 14 metabolite levels (two glycolysis-related metabolites, one amino acid, two ketone bodies, two triglyceride, six lipoprotein subclasses, and an inflammation marker) after Ramadan were partially associated with some changes in nutrient intakes during Ramadan, especially betaine, fructose, glucose, starches and sugars. The lutein/zeaxanthin intake change explained inversely 14% of systolic blood pressure changes. Moreover, BMI and weight changes were partially explained by changes in intake of fat (7%; 9%), monounsaturated fat (6%; 7%), starch (8%; 9%), and starch as monosaccharide equivalents (8%; 9%) intakes in a direct relationship.

Conclusion

Diet changes during Ramadan were associated partially with the observed changes in the metabolic profile, blood pressure and anthropometry. This confirms the changes associated with RIF in the metabolic profile, blood pressure and anthropometry are not an absolute physiological response to the diet transition occurring during Ramadan.

Faris M, G. Albalushi A, Alsaedi F, Khan SA, Khan MA. Sleep disruptions and associated risk factors among Iranians during Ramadan amid COVID-19 pandemic: A nationwide cross-sectional study

The global COVID-19 pandemic has disrupted daily routines and heightened stress levels worldwide, impacting various aspects of health, including sleep. This cross-sectional study conducted in Iran aimed to investigate the impact of Ramadan Intermittent Fasting (RIF) during the pandemic on sleep disturbances and associated risk factors in adults aged ≥ 18 years. Data was collected from Iranian participants observing RIF. A structured electronic questionnaire, translated into Persian, gathered information on sociodemographics, dietary habits, sleep parameters, physical activity, and more. The study assessed sleep quality, duration, and disturbances and conducted a thorough analysis to identify risk factors associated with sleep disruptions. The study revealed that 48% of the participants experienced sleep disturbances during RIF, with 21% reporting poor sleep quality and 46% having unusual sleep duration. Various factors were associated with an elevated risk of sleep disruptions, including body mass index, place of residence, income levels, cohabitation status, family history of obesity, hypertension, diabetes, heart disease, personal history of obesity, weight fluctuations, Shisha smoking, and unemployment. The results highlight the critical importance of health promotion strategies tailored to cultural contexts. This study advocates for enhanced health education initiatives focusing on sleep hygiene and stress management, especially during periods of significant lifestyle alterations like Ramadan amid a global pandemic. Such initiatives are vital in mitigating sleep disturbances and promoting overall well-being in populations facing unique health challenges.

Effects of Modified Ramadan Fasting on Mental Well-Being and Biomarkers in Healthy Adult Muslims - A Randomised Controlled Trial

BACKGROUND

Ramadan fasting has seen increased attention in research, often with inconsistent findings. This study aims to investigate whether dietary and lifestyle modifications during Ramadan can improve well-being and health in healthy adult Muslims.

METHOD

A randomised controlled trial with two parallel groups was conducted in an outpatient clinic of a university hospital in Essen, Germany, in 2016. Healthy adult Muslims (n = 114) aged 18-60 years were randomised to a modified fasting group; i.e., they received educational material prompting dietary and lifestyle modifications pre-Ramadan, and a control group who undertook Ramadan fasting as usual. Primary outcome was quality of life (WHO-5 Well-Being Index). Secondary outcomes included sleep quality, spirituality, and mindfulness (all self-report), body weight, body mass index, body fat, waist circumference, hip circumference, blood pressure, and heart rate, as well as blood serum biomarkers. Safety was examined via adverse events.

RESULTS

The modified fasting group reported significantly higher quality of life (WHO-5) compared to the control after Ramadan (MD 5.9; 95% CI, 0.02-11.8; p < 0.05). Group differences in favour of the modified fasting were also found for satisfaction with health (MD 5.9, 95% CI 0.19-11.67), ease of life (MD 4.1, 95% CI 0.38-7.80) and mindfulness (MD 7.6, 95% CI 2.68-12.52), reductions in weight (MD, - 0.9 kg; 95% CI - 1.39 to - 0.42), BMI (MD - 0.3 kg/m2, 95% CI - 0.50 to - 0.15), hip circumference (MD - 0.3 kg/m2, 95% CI - 0.50 to - 0.15), and diastolic blood pressure (MD - 2.8 mmHg, 95% CI - 5.15 to - 0.43). About 60% of participants reported adverse events, mostly headaches/migraines, dizziness/fatigue, common cold, and gastrointestinal symptoms, with no group differences. One serious non-related adverse event each occurred in both groups.

CONCLUSION

Pre-Ramadan dietary and lifestyle advice can lead to short-term improvements in mental and physical well-being of adult Muslims observing Ramadan. As such, this study demonstrates the potential benefits of culturally appropriate health interventions in a religious context.

TRIAL REGISTRATION

ClinicalTrials.gov (Identifier NCT02775175).

The effects of time-restricted eating and Ramadan fasting on gut microbiota composition: a systematic review of human and animal studies

CONTEXT

It is well known that the microbiome undergoes cyclical diurnal rhythms. It has thus been hypothesized that meal timing may affect gut microbial composition, function, and host health.

OBJECTIVE

This review aims to examine the effects of time-restricted eating (TRE) and Ramadan fasting (RF) on the composition of the gut microbiota in animal and human studies. The associations between composition of microbiota and host metabolic parameters are also examined.

DATA SOURCES

A search was performed on the PubMed, Cochrane, Scopus, and Web of Science databases up to December 31, 2022. The search strategy was performed using the Medical Subject Heading (MeSH) terms "intermittent fasting" and "gastrointestinal microbiome" and the key words "Ramadan fasting" and "microbes."

DATA EXTRACTION

Seven human studies (4 TRE and 3 RF) and 9 animal studies (7 TRE, 2 RF-like) were retrieved.

DATA ANALYSIS

TRE and RF in human studies lead to an increase in gut microbial community alpha-diversity. In animal studies (both TRE and RF-like), fasting is not associated with improved alpha-diversity, but enhancement of microbial fluctuation is observed, compared with high-fat diet ad libitum groups. Within Firmicutes and Bacteroidetes phyla, no specific direction of changes resulting from fasting are observed in both animals and human. After TRE or RF, a greater abundance of the Faecalibacterium genus is observed in human studies; changes in Lactobacillus abundance are found in animal studies; and increases in Akkermansia are seen both in humans and in animals fed a feed-pellet diet. Only 2 human studies show a beneficial correlation between microbiota changes and host metabolic (HDL cholesterol) or anthropometric parameters (body mass index).

CONCLUSIONS

These findings support the importance of both regimens in improving the gut microbiota composition. However, based on results of animal studies, it can be suggested that diet remains the essential factor in forming the microbiota's environment.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO registration no. CRD42021278918.

The effect of last meal "Suhoor" timing on diurnal variations in cognitive performance during Ramadan fasting among female athletes

The present study aimed to investigate the effect of the timing of the last meal, "Suhoor", on diurnal variation in cognitive performance during Ramadan intermittent fasting (RIF). In a randomized order, 26 adolescent female athletes (aged 15.9 ± 0.9 y) were tested in three sessions at 7:00 a.m., 12:00 p.m., and 5:00 p.m. across four different conditions: the 10 days preceding Ramadan (PR); the final 12 days of Ramadan (RO): two different conditions: Early Suhoor (SEarly), and Late Suhoor (SLate); and, ultimately, the 10 days immediately after Ramadan (AR) with an in-between recovery period of ≥24 h. During each test session, the oral temperature (OT), simple reaction time test (SRT), choice reaction time test (CRT), attention test (ATT), and mental rotation test (MRT) were evaluated. The Pittsburgh Sleep Quality Index (PSQI) and daily diary intake were assessed across the three periods. Compared to PR, the sleep parameters assessed by the PSQI were significantly lower during the RO and AR periods. However, neither total dietary intake nor OT showed any changes due to RIF. Compared to PR, the afternoon performances of SRT, CRT, ATT, and MRT significantly declined under both the SEarly and SLate conditions. Notably, midday performance decreased only during SLate, while morning performance remained unaffected in both conditions. Additionally, compared to SEarly, these performances were better during SLate in the afternoon and at midday. In summary, nutrient intake timing had a significant effect on the diurnal fluctuations in cognitive functions during Ramadan fasting, particularly around noon and in the afternoon. Our results illustrate the benefits of a late last meal (Suhoor) in preserving optimal morning cognitive abilities and preventing any impairment during the fasted state at midday or in the afternoon, which could affect overall athletic performance.

Impact of Ramadan fasting on vision and headache-related quality of life in women with idiopathic intracranial hypertension: A prospective observational study

BACKGROUND

Ramadan fasting is an obligatory religious practice for Muslims. However, research data on the effect of Ramadan on idiopathic intracranial hypertension (IIH) symptoms are lacking. This study aimed to study the effect of Ramadan fasting on the severity of headache and visual symptoms and related quality-of-life activities.

METHODS

This prospective cohort study targeted females diagnosed with IIH (n = 102) who were eligible to fast for Ramadan in 2023. The patients were recruited from the Neurology Clinic in Beni-Suef University Hospital, Egypt. Body mass index (BMI), monthly headache days and intensity of headache attacks, six-item Headache Impact Test (HIT-6), and the 25-item National Eye Institute Visual Function Questionnaire (NEI-VFQ-25) scores during Ramadan were compared to those during the (non-fasting) month of Shaaban, the preceding month to Ramadan.

RESULTS

There was a significant increase in the BMI of patients with IIH in Ramadan compared to the (non-fasting) month of Shaaban, at a median (interquartile range [IQR]) of 30.5 (26.6-35.8) kg/m2 and 30.1 (26.6-35.2) kg/m2, respectively (p = 0.002). The median (IQR) value of monthly headache days was significantly increased during Ramadan in comparison to the (non-fasting) month of Shaaban, at 20 (11.5-30) vs. 15 (10-25) (p < 0.001). There was a statistically significant worsening in the visual analog scale (VAS) scores (median [IQR] 7 [5-8] vs. 6.5 [5-8]), HIT-6 scores (median [IQR] 61 [58-67] vs. 59 [53-61.5]), and NEI-VFQ-25 total scores (median [IQR] 1312.5 [1238.8-1435] vs 1290 [1165-1417.5]) during Ramadan in comparison to the (non-fasting) month of Shaaban (p < 0.001 for all comparisons). The change in BMI in Ramadan was positively correlated with the change in monthly headache days (r = 0.24, p = 0.014), VAS (r = 0.20, p = 0.043), HIT-6 (r = 0.25, p = 0.010) and NEI-VFQ-25 scores (r = 0.24, p = 0.016).

CONCLUSION

Ramadan fasting had an aggravating effect on headache, visual symptoms, and related quality-of-life activities, which might be attributed to weight gain during this month. Whether proper nutritional management to prevent weight gain during Ramadan may help mitigate this worsening effect is a mission of future studies.

Effect of Ramadan fasting on thyroid functions in hypothyroid patients taking levothyroxine: a systematic review and meta-analysis

BACKGROUND

The major changes in the timing of meals during Ramadan may be challenging for hypothyroid patients on levothyroxine. We aimed to study the effect of Ramadan fasting on thyroid functions in hypothyroid patients taking levothyroxine.

METHODS

We did a comprehensive search of 8 databases for Randomized controlled studies (RCTs) and observational studies investigating the effect of Ramadan fasting on thyroid functions in hypothyroid individuals taking levothyroxine. Relevant data was extracted and analyzed. Mean difference (MD) and standard deviation (SD) were used to evaluate the continuous data. Risk ratios (RR) with a 95% confidence interval were used for outcomes constituting dichotomous data. National Institutes of Health (NIH) tools were used to assess the risk of bias.

RESULTS

Fourteen studies met our inclusion criteria, 3 RCTs, and 11 observational studies, all designed as pre-post studies. Ramadan fasting was associated with a statistically significant increase in TSH in patients who were euthyroid before Ramadan (MD = -0.76 [95% CI; -1.27, -0.25]). However, free thyroxine (FT4) was found to be stable (MD = 0.01, [95% CI; -0.03, 0.06]). All timing points were associated with a significant increase in TSH levels after Ramadan, pre-iftar (MD = -0.69 [95% CI; -1.03, -0.36]), post-iftar (MD = -0.76 [95% CI; -1.12, -0.39]), and pre-suhoor (MD = -1.19 [95% CI; -2.18, -0.19]).

CONCLUSION

TSH increases significantly after Ramadan. No timing point has superiority in maintaining thyroid control. However, choosing the timing should be individualized according to the patient's preference to guarantee the most possible compliance.

The effect of time of eating on cardiometabolic risk in primary and secondary prevention of cardiovascular disease

Continuous energy restriction is currently considered the first-line dietary therapy for weight loss in individuals with obesity. Recently, interventions which alter the eating window and time of eating occasions have been explored as means to achieve weight loss and other cardiometabolic improvements such as a reduction in blood pressure, glycaemia, lipids and inflammation. It is unknown, however, whether these changes result from unintentional energy restriction or from other mechanisms such as the alignment of nutrient intake with the internal circadian clock. Even less is known regarding the safety and efficacy of these interventions in individuals with established chronic noncommunicable disease states, such as cardiovascular disease. This review examines the effects of interventions which alter both eating window and time of eating occasions on weight and other cardiometabolic risk factors in both healthy participants and those with established cardiovascular disease. We then summarise the state of existing knowledge and explore future directions of study.

Chrononutrition in the context of Ramadan: Potential implications

Every year, healthy adult Muslims practice dawn to sunset fasting for a whole lunar month. No food or fluid is allowed for the fasting time window. After sunset, eating is allowed. The dramatic change in the timing of meals is accompanied by changes in sleeping hours and thus alterations in circadian rhythms. Hormonal mechanisms mainly determined by the latter also change. These include shifts in cortisol and melatonin. Food-dependent hormones such as Ghrelin and leptin also show changes. A well-established principle of chrononutrition is that the timing of eating may be as or more important than the content of food. Ramadan fasting (RF) is distinct from other forms of intermittent fasting, although there are also some similarities with time restricted eating (TRE). Both have been shown to have health benefits. Here, we examine existing literature to understand and learn from this very commonly practiced form of fasting and its relationships to circadian rhythms and homoeostatic mechanisms.

Alterations in anthropometric, inflammatory and mental health parameters during Ramadan intermittent fasting in a group of healthy people: a prospective cohort study

Fasting has been practiced with different time span in different areas of the world and for various reasons. One of the types of fasting regimens is Ramadan intermittent fasting (RIF), which is described as intermittent dry fasting and known as the most commonly practiced form of religious fasting. Different studies have shown its effects on body composition parameters and mental health, fatigue and quality of life (QoL). Elucidating the relationship of RIF on biological parameters would also be of importance to show its mechanism. Therefore, we evaluated several biological mediators related to mental health, such as ß-nerve growth factor (ß-NGF), brain-derived neurotrophic factor (BDNF), glial cell line-derived neurotrophic factor (GDNF), and insulin-like growth factor-1 (IGF-1), interleukin-8 (IL-8), tumor necrosis factor-α (TNF-α), and matrix-metalloproteinase-9 (MMP-9). This study consisted of fasting (FG; n = 25) and non-fasting group (NFG; n = 25). Four different time points were assessed for FG: one week before (T1), mid (T2), last days (T3), and one week after (T4) RIF. T1 and T3 were the assessment time points for NFG. Biological mediators were determined from serum samples by using Human Magnetic Luminex and enzyme-linked immunosorbent assay. Furthermore, we then performed correlation analyses between biological mediators and our previously published clinical parameters including body composition and mental health parameters at all time points. Significant alterations were shown in FG for ß-NGF (T2vsT3, p < 0.05; T2vsT4, p < 0.05), GDNF (T1vsT4, p < 0.05; T2vsT4, p < 0.05), IL-8 (T2vsT3, p < 0.05; T3vsT4, p < 0.05), TNF-α (T1vsT3, p < 0.05; T1vsT4, p < 0.001; T2vsT4, p < 0.001), and MMP-9 (T1vsT4, p < 0.01). There were no statistically significant differences between FG and NFG in all biological mediators at T1 and T3. Correlation analysis showed that MMP-9 levels had negative correlation with body mass index (BMI) at T3. At T3 BDNF levels had negative correlation with Epworth Sleepiness Scale (ESS) as one of measured QoL parameters. ß-NGF, GDNF, TNF-α, and MMP-9 had positive correlation with some of body composition and mental health parameters. Findings demonstrate that RIF altered different biological mediators could give benefit to health. Its benefit is mediated by the alteration of biological mediators.

Impact of Ramadan Fasting on Cardiometabolic and InflammatoryBiomarkers among Saudi Adults with Diabetes

BACKGROUND AND AIMS

Diabetes is prevalent in Saudi Arabia. As dietary concerns are central in patients with diabetes, the impact of fasting on health during Ramadan is potentially significant. Decreased meal frequency and changes in food type and amount affect body weight and metabolic profiles. This study aimed to investigate the association between Ramadan fasting and anthropometric measurements and cardiometabolic and inflammatory biomarkers in Saudi adults with diabetes.

METHODS

Sixty-eight Saudi adults with diabetes, admitted at the University Diabetes Centre in Riyadh, Saudi Arabia, were enrolled in this study. Participants were evaluated at the following time points: Six weeks before Ramadan (pre-fasting) and at least 15 days after the initiation of Ramadan (peri-fasting). Anthropometric measurements and cardiometabolic and inflammatory biomarker levels were assessed during both visits.

RESULTS

After accounting for confounding factors, Ramadan fasting was found to be associated with reduced body weight (kg), waist circumference (cm), and hip circumference (cm). Increased log high-density lipoprotein-cholesterol and decreased log interleukin 6 and C-reactive protein levels were observed.

CONCLUSIONS

Ramadan fasting was associated with increased HDL-C levels and decreased anthropometric measurements and inflammatory cytokine levels. These results support the beneficial role of Ramadan fasting in reducing cardiometabolic abnormalities and inflammation in adults with diabetes.

Eating patterns contribute to shaping the gut microbiota in the mucosal simulator of the human intestinal microbial ecosystem

Eating patterns, i.e. meal frequency and circadian timing of meals, are often modified in weight loss and metabolic healing strategies. However, in-depth research into the effects on the gut microbiome remains scarce, particularly across various colon regions and niches. We identified eating patterns to contribute in shaping the in vitro gut biomass production, metabolism, and microbial community compositions by subjecting four faecal microbiomes to a pattern that is standardized for a dynamic gut model (feeding at 09, 17, and 01 h), a typical Western (breakfast, lunch, and dinner at 09, 13, and 19 h, respectively), and a time-restricted pattern (single meal at 09 h). While eating patterns moderately affected the microbiome (2.4% and 1.8% significant variation in proportional and quantitative microbial compositions, respectively), significant changes were noted in the time-restricted pattern, including increased Bacteroides, Butyricicoccus, Dialister, and Faecalibacterium abundances. Sampling every 4 h revealed no significant circadian fluctuations in biomass production, microbial community compositions, or functionality. Longer fasting times favoured the growth of slower-growing species, such as Akkermansia, Dialister, and Parasutterella over faster-growers, such as Pseudomonas and Stenotrophomonas. Our findings illustrate the importance of recording and considering eating patterns as a gut microbiome determinant in in vivo and in vitro dietary intervention studies.

Ramadan intermittent fasting is associated with ameliorated inflammatory markers and improved plasma sphingolipids/ceramides in subjects with obesity: lipidomics analysis

Intermittent fasting (IF) is associated with enormous metabolic alterations that underpin its diverse health effects. Changes in lipid metabolism, particularly ceramides, and other sphingolipids, are among the most notable of these alterations. This study investigated the lipidomic alterations associated with 29-30 days of Ramadan diurnal intermittent fasting (RIF) in metabolically healthy overweight and obese subjects. A prospective cohort of 57 overweight and obese adults (70% males, 38.4 ± 11.2 years), with an age range of 18-58 years was observed prior to and at the conclusion of Ramadan. At both time points, anthropometric, biochemical (lipid profile, glycemic, and inflammatory markers), and dietary intake measurements were taken. Using liquid chromatography-mass spectrometry, a lipidomic analysis of ceramides and other sphingolipids was conducted. Using paired sample t-tests, pre- and post-Ramadan anthropometric, biochemical, and dietary values were compared. RIF was associated with improved levels of lipid profile compartments and inflammatory markers. In addition, RIF was associated with a decrease in plasma sphingosine and sphinganine, which was accompanied by a decrease in sphingosine 1-phosphate and sphinganine 1-phosphate. In addition, RIF was associated with decreased C17, C22, and C24 sphingomyelin, but not C14, C16, C18, C20, and C24:1 sphingomyelin, as well as C20, C22, C24, and C24:1 dihydrosphingomyelin, but not C16 and C18 dihydrosphingomyelin. This study demonstrates that RIF is associated with improvements in plasma sphingosine, sphinganine sphingomyelin, and dihydrosphingomyelin lipid species, as well as improved lipid profile and inflammatory markers, which may confer short-term protection against cardiometabolic problems in patients with overweight/obesity.

Ramadan Fasting and Short-Term Maximal Physical Performance: Searching for Optimal Timing of the Last Meal "Suhoor" in Female Pre-University Handball Players

Aiming to identify the ideal suhoor timing for maintaining optimal physical performance and health indicators during Ramadan intermittent fasting, the present study compares the effects of early vs. late Suhoor on short-term high-intensity physical exercise while controlling the body mass index (BMI) oral temperature (OT), dietary intake, and sleep patterns. In a randomized design, 19 female pre-university handball players (age: 16.8 ± 0.4 y; height: 1.70 ± 0.9 m; and body mass: 61.5 ± 6.9 kg) underwent two test sessions (at 08:00 a.m. and 05:00 p.m.) at four different conditions: ten days prior to Ramadan (R - 10), the final ten days of Ramadan (R) including both Early Suhoor R(ES) and Late Suhoor R(LS) conditions, and the ten days immediately following Ramadan (R + 10). A recovery period of at least 48 h has been set between successive test sessions at each period. Outcome measures included the Countermovement Jumps Test (CMJ), Modified Agility t-Test (MATT), Repeated Sprint Ability (RSA), and Rating of Perceived Exertion (RPE). The Pittsburgh Sleep Quality Index (PSQI), OT, BMI, and daily diary intake were assessed across the three periods. The total scores of PSQI decreased significantly during R and R + 10 compared to R - 10. When performed in the afternoon, CMJ, MATT, and RSA performance decreased significantly at R(ES) and R(LS) conditions compared to R - 10. However, these performances decreased only after R(ES) when performed in the morning. Furthermore, performances were lower during R(ES) compared to R(LS) in the afternoon for all tests and the morning for MATT and RSA tests. These findings support prior research showing a deterioration of physical performance during Ramadan fasting and indicate a more pronounced impact following early Suhoor condition. Therefore, consuming a late suhoor, closer to pre-dawn time, could be suggested as an effective strategy to minimize physical performance decline during short-term high-intensity exercise.

Effects of Ramadan intermittent fasting on gut microbiome: is the diet key?

Much research has been conducted regarding the impact of diet on the gut microbiota. However, the effects of dietary habits such as intermittent fasting are unclear. This study aimed to investigate the effect of intermittent fasting during Ramadan on the gut microbiota. The study was conducted on 12 healthy adult individuals who practiced fasting 17 h per day for 29 consecutive days during the month of Ramadan. To determine the dietary intake of individuals, a 3-day dietary record was kept at the beginning and end of the study. Reads that passed quality filtering were clustered, and custom-prepared 16S rRNA gene regions of bacteria associated with the human microbiome were used as a reference. Consensus sequences were created, and genus-level taxonomic annotations were determined using a sequence identity threshold of 95%. The correlations between the dietary intake measurements of the participants and the respective relative abundance of bacterial genera were investigated. The results showed that Firmicutes were higher in abundance in the gut microbiota before fasting among participants, while they were significantly lower in abundance at the end of Ramadan fasting (p < 0.05). Proteobacteria were significantly higher in abundance at the end of the month of Ramadan (p < 0.05). Fasting was associated with a significant decrease in levels of seven genera: Blautia, Coprococcus, Dorea, Faecalicatena, Fusicatenibacter, Lachnoclostridium, and Mediterraneibacter. Conversely, the abundances of two bacterial genera were enhanced at the end of the fasting month: Escherichia and Shigella. The results of the dietary intake analysis showed that a negative correlation was detected for three comparisons: Ihubacter and protein (rho = -0.54, p = 0.0068), Fusicatenibacter and vegetables (rho = -0.54, p = 0.0042), and Intestinibacter and nuts (rho = -0.54, p-value = 0.0065). The results suggest that even when the fasting period during Ramadan is consistent, the types of food consumed by individuals can affect the gut microbiota.

Changes in dietary and lifestyle behaviors and mental stress among medical students upon Ramadan diurnal intermittent fasting: a prospective cohort study from Taif/Saudi Arabia

BACKGROUND

Intermittent fasting (IF) is a popular dietary plan for weight loss. In fact, fasting is a common practice in different religions such as Buddhism, Hinduism, Judaism, Christianity, and Islam. During the month of Ramadan, more than 1.5 billion Muslims worldwide fast from dawn to sunset. Ramadan diurnal intermittent fasting (RDIF) has health benefits, including a reduction in cardiovascular disease (CVD) risk and an improvement in mood. However, little is known about the effects of RDIF on lifestyle behaviors, such as regular exercise, consuming healthy diet, and avoiding harmful substances, as well as mental stress, and academic performance in high school and university students.

METHODS

In this prospective cohort study, two self-reported questionnaires were sent one week before and during the last week of Ramadan (April 2022; Ramadan 1443 in Hijri Islamic Calendar) to assess changes in lifestyle, perceived stress, and academic achievement of medical students at Taif University in Taif city, Saudi Arabia. Healthy lifestyle components data were collected to calculate healthy lifestyle scores, including body mass index, physical activity, adherence to a Mediterranean diet, smoking status, and sleep duration.

RESULTS

RDIF was associated with a healthier lifestyle in both female and male participants (pre-RDIF mean score: 2.42 vs post-RDIF mean score: 2.74; statistical power = 0.99; P-value < 0.05). They were more active and adherent to the Mediterranean diet during RDIF. Additionally, the post-RDIF smoking rate declined by 53.4%. Male participants showed higher perceived stress scores during RDIF (pre-RDIF mean score: 19.52 vs post-RDIF mean score: 22.05; P-value < 0.01). No changes in academic performance were observed upon RDIF.

CONCLUSION

Medical students show healthier dietary and lifestyle behaviors and their academic performance is not affected during RDIF. However, perceived stress is higher among male students.

Interventions for people with type 2 diabetes mellitus fasting during Ramadan

BACKGROUND

Fasting during Ramadan is obligatory for adult Muslims, except those who have a medical illness. Many Muslims with type 2 diabetes (T2DM) choose to fast, which may increase their risks of hypoglycaemia and dehydration.

OBJECTIVES

To assess the effects of interventions for people with type 2 diabetes fasting during Ramadan.

SEARCH METHODS

We searched CENTRAL, MEDLINE, PsycINFO, CINAHL, WHO ICTRP and ClinicalTrials.gov (29 June 2022) without language restrictions.

SELECTION CRITERIA

Randomised controlled trials (RCTs) conducted during Ramadan that evaluated all pharmacological or behavioural interventions in Muslims with T2DM.

DATA COLLECTION AND ANALYSIS

Two authors screened and selected records, assessed risk of bias and extracted data independently. Discrepancies were resolved by a third author. For meta-analyses we used a random-effects model, with risk ratios (RRs) for dichotomous outcomes and mean differences (MDs) for continuous outcomes with their associated 95% confidence intervals (CIs). We assessed the certainty of evidence using the GRADE approach.

MAIN RESULTS

We included 17 RCTs with 5359 participants, with a four-week study duration and at least four weeks of follow-up. All studies had at least one high-risk domain in the risk of bias assessment. Four trials compared dipeptidyl-peptidase-4 (DPP-4) inhibitors with sulphonylurea. DPP-4 inhibitors may reduce hypoglycaemia compared to sulphonylureas (85/1237 versus 165/1258, RR 0.53, 95% CI 0.41 to 0.68; low-certainty evidence). Serious hypoglycaemia was similar between groups (no events were reported in two trials; 6/279 in the DPP-4 versus 4/278 in the sulphonylurea group was reported in one trial, RR 1.49, 95% CI 0.43 to 5.24; very low-certainty evidence). The evidence was very uncertain about the effects of DPP-4 inhibitors on adverse events other than hypoglycaemia (141/1207 versus 157/1219, RR 0.90, 95% CI 0.52 to 1.54) and HbA1c changes (MD -0.11%, 95% CI -0.57 to 0.36) (very low-certainty evidence for both outcomes). No deaths were reported (moderate-certainty evidence). Health-related quality of life (HRQoL) and treatment satisfaction were not evaluated. Two trials compared meglitinides with sulphonylurea. The evidence is very uncertain about the effect on hypoglycaemia (14/133 versus 21/140, RR 0.72, 95% CI 0.40 to 1.28) and HbA1c changes (MD 0.38%, 95% CI 0.35% to 0.41%) (very low-certainty evidence for both outcomes). Death, serious hypoglycaemic events, adverse events, treatment satisfaction and HRQoL were not evaluated. One trial compared sodium-glucose co-transporter-2 (SGLT-2) inhibitors with sulphonylurea. SGLT-2 may reduce hypoglycaemia compared to sulphonylurea (4/58 versus 13/52, RR 0.28, 95% CI 0.10 to 0.79; low-certainty evidence). The evidence was very uncertain for serious hypoglycaemia (one event reported in both groups, RR 0.90, 95% CI 0.06 to 13.97) and adverse events other than hypoglycaemia (20/58 versus 18/52, RR 1.00, 95% CI 0.60 to 1.67) (very low-certainty evidence for both outcomes). SGLT-2 inhibitors result in little or no difference in HbA1c (MD 0.27%, 95% CI -0.04 to 0.58; 1 trial, 110 participants; low-certainty evidence). Death, treatment satisfaction and HRQoL were not evaluated. Three trials compared glucagon-like peptide 1 (GLP-1) analogues with sulphonylurea. GLP-1 analogues may reduce hypoglycaemia compared to sulphonylurea (20/291 versus 48/305, RR 0.45, 95% CI 0.28 to 0.74; low-certainty evidence). The evidence was very uncertain for serious hypoglycaemia (0/91 versus 1/91, RR 0.33, 95% CI 0.01 to 7.99; very low-certainty evidence). The evidence suggests that GLP-1 analogues result in little to no difference in adverse events other than hypoglycaemia (78/244 versus 55/255, RR 1.50, 95% CI 0.86 to 2.61; very low-certainty evidence), treatment satisfaction (MD -0.18, 95% CI -3.18 to 2.82; very low-certainty evidence) or change in HbA1c (MD -0.04%, 95% CI -0.45% to 0.36%; 2 trials, 246 participants; low-certainty evidence). Death and HRQoL were not evaluated. Two trials compared insulin analogues with biphasic insulin. The evidence was very uncertain about the effects of insulin analogues on hypoglycaemia (47/256 versus 81/244, RR 0.43, 95% CI 0.13 to 1.40) and serious hypoglycaemia (4/131 versus 3/132, RR 1.34, 95% CI 0.31 to 5.89) (very low-certainty evidence for both outcomes). The evidence was very uncertain for the effect of insulin analogues on adverse effects other than hypoglycaemia (109/256 versus 114/244, RR 0.83, 95% CI 0.44 to 1.56; very low-certainty evidence), all-cause mortality (1/131 versus 0/132, RR 3.02, 95% CI 0.12 to 73.53; very low-certainty evidence) and HbA1c changes (MD 0.03%, 95% CI -0.17% to 0.23%; 1 trial, 245 participants; very low-certainty evidence). Treatment satisfaction and HRQoL were not evaluated. Two trials compared telemedicine with usual care. The evidence was very uncertain about the effect of telemedicine on hypoglycaemia compared with usual care (9/63 versus 23/58, RR 0.42, 95% CI 0.24 to 0.74; very low-certainty evidence), HRQoL (MD 0.06, 95% CI -0.03 to 0.15; very low-certainty evidence) and HbA1c change (MD -0.84%, 95% CI -1.51% to -0.17%; very low-certainty evidence). Death, serious hypoglycaemia, AEs other than hypoglycaemia and treatment satisfaction were not evaluated. Two trials compared Ramadan-focused patient education with usual care. The evidence was very uncertain about the effect of Ramadan-focused patient education on hypoglycaemia (49/213 versus 42/209, RR 1.17, 95% CI 0.82 to 1.66; very low-certainty evidence) and HbA1c change (MD -0.40%, 95% CI -0.73% to -0.06%; very low-certainty evidence). Death, serious hypoglycaemia, adverse events other than hypoglycaemia, treatment satisfaction and HRQoL were not evaluated. One trial compared drug dosage reduction with usual care. The evidence is very uncertain about the effect of drug dosage reduction on hypoglycaemia (19/452 versus 52/226, RR 0.18, 95% CI 0.11 to 0.30; very low-certainty evidence). No participants experienced adverse events other than hypoglycaemia during the study (very low-certainty evidence). Death, serious hypoglycaemia, treatment satisfaction, HbA1c change and HRQoL were not evaluated.

AUTHORS' CONCLUSIONS

There is no clear evidence of the benefits or harms of interventions for individuals with T2DM who fast during Ramadan. All results should be interpreted with caution due to concerns about risk of bias, imprecision and inconsistency between studies, which give rise to low- to very low-certainty evidence. Major outcomes, such as mortality, health-related quality of life and severe hypoglycaemia, were rarely evaluated. Sufficiently powered studies that examine the effects of various interventions on these outcomes are needed.

The Effect of Ramadan Intermittent Fasting on Food Intake, Anthropometric Indices, and Metabolic Markers among Premenopausal and Postmenopausal Women: A Cross-Sectional Study

Background and objectives: Ramadan intermittent fasting (RIF) is a monthlong practice in which Muslims fast during the whole day from sunrise to sunset. During this month, fasting people change their dietary behavior and alter their eating hours from day to night. The objective of the current study was to examine the effect of RIF on dietary consumption, anthropometric indices, and metabolic markers in healthy premenopausal (PRE-M) and postmenopausal (POST-M) Saudi women. Materials and Methods: The study included 62 women (31 PRE-M, 21-42 years, and 31 POST-M, 43-68 years). A structured questionnaire was used to collect socioeconomic data. Physical activity, anthropometric, dietary, and biochemical assessments were assessed before and at the end of the third week of Ramadan. Results: Socioeconomic data varied among participants. For both groups, observing RIF was associated with significantly (at either p ≤ 0.01 or p ≤ 0.05) lower intake of calories, macronutrients, minerals (excluding Na), and vitamins than before RIF. For the PRE-M group, the percentage of overweight participants decreased significantly (p ≤ 0.01) during Ramadan, while the percentage of obese participants remained unchanged. In contrast, for the POST-M group, the percentage of overweight participants increased significantly (p ≤ 0.05) during Ramadan, but dropped at the end of Ramadan. Following RIF, waist-to-hip ratio, body fat, and fat mass (FM) decreased in both groups. High-density lipoprotein cholesterol (HDL-C), fasting blood glucose (FBG), triglycerides (TG), and blood pressure (SBP, DBP) were generally maintained at acceptable normal levels in most participants before and at the end of RIF. However, low-density lipoprotein cholesterol (LDL-C) at the end of RIF was significantly lower than before, particularly in POST-M women. Age, occupation, and monthly income were the most important predictors for the changes in nutritional status and body fat upon RIF. Conclusions: observing RIF by PRE-M and POST-M Saudi women was associated with significant improvements in variable health indicators, with a few exceptions, and may help lower risk factors for chronic diseases, particularly among POST-M women. However, further studies with a larger sample size are required to determine and confirm the exact effect of RIF on these groups.

Implications of Ramadan Fasting in the Setting of Gastrointestinal Disorders

Intermittent fasting is an increasingly popular dieting technique with many well-studied benefits, such as permitting weight loss in obese patients, lowering low-density lipoprotein cholesterol (LDL-C) levels and triglyceride levels, and optimizing circadian rhythms. A special type of intermittent fasting occurs during Ramadan, when Muslims worldwide fast daily from dawn to sunset for a month. Ramadan fasting has demonstrated several health benefits, including improving the gut microbiome, modifying gut hormone levels, and lowering proinflammatory markers such as cytokines and blood lipids. Although fasting has many health benefits, fasting during Ramadan may aggravate chronic medical conditions. We aim to review the literature devoted to Ramadan fasting and its effects on Muslim patients with gastrointestinal (GI) disorders, such as Inflammatory bowel disease (IBD), peptic ulcer disease (PUD), upper GI bleeding (UGIB), gastroesophageal reflux disease (GERD), and liver conditions. We will discuss recommendations for diet and medication compliance during Ramadan in the recommended pre-Ramadan counseling sessions. In this study, we used PubMed to research journals using the key terms "Ramadan," "intermittent fasting," and "gastrointestinal diseases." The current literature studying the impact of Ramadan on gastrointestinal disorders shows that patients with IBD have a minimal risk of disease exacerbation, although older men with ulcerative colitis (UC) were more prone to exacerbation during fasting. Patients with duodenal ulcers were at a higher risk of hemorrhage after Ramadan fasting. Although with mixed results, studies show patients with liver disease demonstrated improvements in liver enzymes, cholesterol, and bilirubin after Ramadan. Physicians should offer pre-Ramadan counseling to educate patients on the risks of fasting and encourage shared decision-making. To facilitate more definitive discussions between the physician and a Muslim patient, clinicians should seek a deeper understanding of how Ramadan fasting affects certain health conditions and offer accommodations, such as diet and medication adjustments.

Examination of sleep in relation to dietary and lifestyle behaviors during Ramadan: A multi-national study using structural equation modeling among 24,500 adults amid COVID-19

BACKGROUND

Of around 2 billion Muslims worldwide, approximately 1.5 billion observe Ramadan fasting (RF) month. Those that observe RF have diverse cultural, ethnic, social, and economic backgrounds and are distributed over a wide geographical area. Sleep is known to be significantly altered during the month of Ramadan, which has a profound impact on human health. Moreover, sleep is closely connected to dietary and lifestyle behaviors.

METHODS

This cross-sectional study collected data using a structured, self-administered electronic questionnaire that was translated into 13 languages and disseminated to Muslim populations across 27 countries. The questionnaire assessed dietary and lifestyle factors as independent variables, and three sleep parameters (quality, duration, and disturbance) as dependent variables. We performed structural equation modeling (SEM) to examine how dietary and lifestyle factors affected these sleep parameters.

RESULTS

In total, 24,541 adults were enrolled in this study. SEM analysis revealed that during RF, optimum sleep duration (7-9 h) was significantly associated with sufficient physical activity (PA) and consuming plant-based proteins. In addition, smoking was significantly associated with greater sleep disturbance and lower sleep quality. Participants that consumed vegetables, fruits, dates, and plant-based proteins reported better sleep quality. Infrequent consumption of delivered food and infrequent screen time were also associated with better sleep quality. Conflicting results were found regarding the impact of dining at home versus dining out on the three sleep parameters.

CONCLUSION

Increasing the intake of fruits, vegetables, and plant-based proteins are important factors that could help improve healthy sleep for those observing RF. In addition, regular PA and avoiding smoking may contribute to improving sleep during RF.

Effects of Ramadan Fasting on Glycaemic Control Among Patients with Type 2 Diabetes: Systematic Review and Meta-analysis of Observational Studies

INTRODUCTION

The prevalence of type 2 diabetes (T2D) is increasing around the world. Although Muslims with a physical illness are exempted from fasting during the month of Ramadan, a great number still choose to fast, often without medical consultations. The aim of this systematic review and meta-analysis was to investigate the impact of observing Ramadan fasting (RF) on glycaemic control in patients with T2D.

METHODS

The Web of Science, Scopus, EBSCOhost, CINAHL, ScienceDirect, Cochrane Library, ProQuest Central and Europe PubMed Central (Medline) databases were searched for relevant studies published between January 2000 and December 2021. Observational studies that examined the changes in body weight (BW) and glucose parameters (glycosylated haemoglobin [HbA1c] and fasting blood glucose [FBG]), before and after RF among different age groups with T2D were included in the systemic review and meta-analysis. Effect sizes for the tested outcomes were calculated as weighted mean difference (WMD), with their confidence intervals (CI). Quality assessment was examined using the National Heart, Lung, and Blood Institute (NHLBI) tool.

RESULTS

Of the 1592 identified records, 12 studies conducted in Middle Eastern and Asian countries were eligible and included in the quantitative analyses. The quality of the retrieved studies was evaluated and found to range between fair (83%) and good (17%). These 12 studies included 5554 participants of whom 54% were males and 46% were females. Our pooled analysis demonstrated that HbA1c and FBG levels significantly decreased after RF when compared to the pre-fasting levels (WMD = 0.55 mg/dl, 95% CI 0.33-0.77, P < 0.00001, Ι² = 93% and WMD = 12.42, CI 6.46-18.38, P < 0.0001, Ι² = 81%, respectively). However, the difference in BW in fasting patients after RF versus the pre-fasting stage was non-significant. Although, young patients with T2D were enrolled in the 12 selected studies, we did not find any studies that solely focussed on this group.

CONCLUSION

The impact of RF on adult patients with T2D is associated with favorable outcomes. However, future studies should evaluate data from young adults separately. In addition, it is essential to identify the effects of the number of fasting days (level of exposure), diet, level of physical activity and sleeping pattern on optimal glycaemic control. This information could be utilized by medical professionals as a non-pharmacological therapeutic method for management of diabetes in patients who are willing to practice fasting during Ramadan and other months of the year.

STUDY REGISTRATION

PROSPERO: CRD42022314752.

Ramadan diurnal intermittent fasting is associated with significant plasma metabolomics changes in subjects with overweight and obesity: A prospective cohort study

Introduction

During the holy month of Ramadan, adult healthy Muslims are mandated to abstain from dawn to sunset, with free eating at night hours that may extend up to 12 h. The current work was designed to investigate the metabolomics changes incurred upon the observance of Ramadan diurnal intermittent fasting (RDIF).

Methods

Twenty-five metabolically healthy participants with overweight and obesity (7 females and 18 males, with a mean age of 39.48 ± 10.0 years) were recruited for the study and were followed before and at the end of RDIF month. Dietary, anthropometric, biochemical, and physical activity assessments were performed before and at the end of the fasting month. The metabolomic assay was performed using liquid chromatography-mass spectrometry for the two-time points.

Results and discussion

Metabolomics assay revealed a significant reduction in a few metabolites. The analysis revealed that 27 metabolites differed significantly (P < 0.05) between pre-and post-RDIF. Among the differentially abundant metabolites, 23 showed a decrease with fasting, these included several amino acids such as aspartame, tryptophan, phenylalanine, histidine, and other metabolites including valeric acid, and cortisol. On the other hand, only four metabolites showed increased levels after RDIF including traumatic acid, 2-pyrrolidinone, PC[18:1(9Z)/18:1(9Z)], and L-sorbose. The MetaboAnalyst^® platform reported that the top enriched metabolic pathways included: (1) histidine metabolism; (2) folate biosynthesis (3) phenylalanine, tyrosine, and tryptophan biosynthesis; (4) aminoacyltRNA biosynthesis; (5) caffeine metabolism; (6) vitamin B₆ metabolism; and several other pathways relating to lipid metabolisms such as arachidonic acid metabolism, glycerophospholipid metabolism, and linoleic acid metabolism. In conclusion, RDIF entails significant changes in various metabolic pathways that reflect different dietary and lifestyle behaviors practiced during the fasting month.

Sugar Reduction Initiatives in the Eastern Mediterranean Region: A Systematic Review

This systematic review aims to identify and characterize existing national sugar reduction initiatives and strategies in the Eastern Mediterranean Region. For this purpose, a systematic review of published and grey literature was performed. A comprehensive list of search terms in the title/abstract/keyword fields was used to cover the four following concepts (1) sugar, (2) reduction OR intake, (3) policy and (4) EMR countries. A total of 162 peer-reviewed documents were identified, until the 2nd of August 2022. The key characteristics of the identified national strategies/initiatives included the average sugar intake of each country's population; sugar levels in food products/beverages; implementation strategies (taxation; elimination of subsidies; marketing regulation; reformulation; consumer education; labeling; interventions in public institution settings), as well as monitoring and evaluation of program impact. Twenty-one countries (95%) implemented at least one type of sugar reduction initiatives, the most common of which was consumer education (71%). The implemented fiscal policies included sugar subsidies' elimination (fourteen countries; 67%) and taxation (thirteen countries 62%). Thirteen countries (62%) have implemented interventions in public institution settings, compared to twelve and ten countries that implemented food product reformulation and marketing regulation initiatives, respectively. Food labeling was the least implemented sugar reduction initiative (nine countries). Monitoring activities were conducted by four countries only and impact evaluations were identified in only Iran and Kingdom of Saudi Arabia (KSA). Further action is needed to ensure that countries of the region strengthen their regulatory capacities and compliance monitoring of sugar reduction policy actions.

Religious fasting and its impacts on individual, public, and planetary health: Fasting as a "religious health asset" for a healthier, more equitable, and sustainable society

Religious fasting is practiced by people of all faiths, including Christianity, Islam, Buddhism, Jainism, as well as Hinduism, Judaism, and Taoism. Individual/clinical, public, global, and planetary health has traditionally been studied as separate entities. Nevertheless, religious fasting, in conjunction with other religious health assets, can provide several opportunities, ranging from the individual to the population, environmental, and planetary levels, by facilitating and supporting societal transformations and changes, such as the adoption of healthier, more equitable, and sustainable lifestyles, therein preserving the Earth's systems and addressing major interconnected, cascading, and compound challenges. In this review, we will summarize the most recent evidence on the effects of religious fasting, particularly Orthodox and Ramadan Islamic fasting, on human and public health. Further, we will explore the potential effects of religious fasting on tackling current environmental issues, with a special focus on nutrition/food restriction and planetary health. Finally, specific recommendations, particularly around dietary intake during the fasting rituals, will be provided to ensure a sustainable healthy planet.

Nigerian Muslim's Perceptions of Changes in Diet, Weight, and Health Status during Ramadan: A Nationwide Cross-Sectional Study

The Islamic month of Ramadan is marked by fasting, when Muslims refrain from eating and drinking from dawn to sunset, which has an impact on their dietary habits. The study aimed to assess Nigerian Muslims' dietary modifications during Ramadan and their related changes in body weight and health status. A web-based cross-sectional study was conducted among Nigerian adult Muslims. The survey assessed sociodemographic, dietary habits, eating behaviors, food choices, perceived weight changes, and health status. The logistic regression model was used to assess the predictors of weight change and perceived health status. There were 770 participants, 62.9% of whom were women, ranging in age from 18 to 60 years with a mean age of 27.7 ± 6.4 years. Fruits, palm dates, homemade foods, milk products, and vegetables were more frequently consumed. There were fewer energy drinks, pastries, salty snacks, and carbonated or sugared drinks consumed during Ramadan than before. Over half (54.6%, 95% CI: 51.0-58.9%) of the respondents lost weight during Ramadan, 37.0% (95% CI: 17.4-38.6%) maintained their weight and 8.4% (95% CI: 6.6-10.6%) gained weight during the month. Nearly all (97.3%, 95% CI: 95.8-98.3%) reported having good health during Ramadan, and 2.7% (95% CI: 1.7-4.1%) reported having a poorer health state during Ramadan. There was a significant weight loss and healthy dietary change associated with Ramadan fasting in Nigeria. Public health measures must be in place to impart such positive health behaviors so that such healthy habits continue throughout the year.

Intermittent Fasting-Short- and Long-Term Quality of Life, Fatigue, and Safety in Healthy Volunteers: A Prospective, Clinical Trial

Background: Intermittent fasting (IF) is defined as an eating pattern without calorie restrictions, alternating between periods of fasting and eating. In the past decades IF has not only become a popular weight-reducing diet but is thought to improve Quality of Life (QoL) and fatigue. However, very little evidence exists for the general population. Thus, we aimed to assess the impact of a 16-h fasting period per day over a three-month study period on QoL and especially fatigue in healthy people. Methods: We conducted a prospective cohort study including healthy subjects. All participants fasted 16 h for at least five days a week while maintaining their normal lifestyle. In the study, we analysed blood samples as well as QoL through standardized questionnaires (WHO-5 questionnaire, Short Form Health 36). Furthermore, we measured the degree of fatigue with the Fatigue Assessment Scale (FAS) and Fatigue Severity Scale (FSS) as well as compliance, activity records, and weight alterations. All endpoints were evaluated at baseline, after two weeks, four weeks, and three months of IF. Results: A total of 30 participants fasted for the entire study period. The results of the WHO-5 questionnaire (15.6 ± 4.6 vs. 18 ± 3.6, p < 0.0019) demonstrated a significant increase in QoL. For long-term QoL six out of eight domains measured by the Short Form Health 36 (SF-36) significantly improved (e.g., physical health: 92.3 ± 11.6 vs. 96.5 ± 6.3, p = 0.015; mental health: 75.5 ± 12.0 vs. 81.7 ± 9.0; p < 0.001 and body pain: 74.1 ± 31.8 vs. 89.5 ± 14.9; p = 0.008) after three months. Fatigue significantly decreased from 10.3 ± 3.2 to 8.4 ± 2.5; p = 0.002 for mental fatigue and from 12.6 ± 3.8 to 10.7 ± 3.3; p = 0.002 measured by the FAS. The mean FSS-Score at baseline was 3.5 ± 1.2 compared to 2.9 ± 1.1 (scale 1−7) after three months (p < 0.001). Notably, the proliferation marker IGF-1 was significantly reduced. No clinically significant changes in laboratory parameters were observed that would have endangered a participant’s safety. Conclusions: IF according to the 16:8 regime over a fasting period of three months significantly improved several aspects of the QoL and decreased fatigue in healthy people, while maintaining a good safety profile. The practicability of this diet was also demonstrated for shift workers and people with a high percentage of active labour. Apart from the improvement in QoL and fatigue, the significant reduction in IGF-1, which can act as an accelerator of tumour development and progression, might be an indicator of the potential benefits of IF for patients with cancer.

Changes in dietary intake, chronotype and sleep pattern upon Ramadan among healthy adults in Jeddah, Saudi Arabia: A prospective study

Background

Notable lifestyle changes can occur in Ramadan due to the sudden shift in eating routine with fasting during daylight hours. This study aimed to examine the changes in dietary intakes, chronotype, sleep pattern, and physical activity level before and during Ramadan in healthy adults.

Methods

This study was conducted in Jeddah city, Saudi Arabia, and convenience sampling was used. To compare dietary, chronotype and sleep pattern changes before and during Ramadan, data were collected in two separate periods: the first period was 2 months before Ramadan, and the second period was during the last 3 weeks of Ramadan. Dietary intake was assessed using 24-h food recall and chronotype using Morningness-Eveningness Questionnaire. Daytime sleepiness and sleep duration were assessed using the Epworth sleepiness scale and a sleep diary for seven consecutive days, respectively. Anthropometric measurements were also taken across the study periods.

Results

A total of 115 adults (96 females and 19 males) were included in the study. Significant increases in daily calorie and carbohydrate intakes during Ramadan than before Ramadan were noted (calorie intake: 1,482.9 ± 536.4 kcal/day before Ramdan vs. 1,635.5 ± 635.1 kcal/day during Ramadan; carbohydrate intake: 180.8 ± 72.1 g/day before Ramadan vs. 202.6 ± 88.7 g/day during Ramadan; p < 0.05). Chronotypes and daytime sleepiness were also associated significantly with Ramadan fasting. A significant slight reduction in body weight during Ramadan was observed (66.4 ± 18.1 kg before Ramdan vs. 66.1 ± 17.8 kg before Ramadan and during Ramadan, respectively; p < 0.05).

Conclusion

This study indicates that Ramadan diurnal fasting was associated with greater calorie and carbohydrate intake, changes in chronotype, and daytime sleepiness. The study also suggests that Ramadan diurnal fasting model may be a promising weight loss strategy.

Assessment of water consumption during Ramadan intermittent fasting: Result from Indonesian cross-sectional study

During Ramadan fasting, people are likely to consume water and beverages lower than recommended intake due to the limited time. However, it is necessary to achieve the recommended daily water intake to maintain the hydration status, as well as productivity during fasting. Unfortunately, there is a lack of data on drinking patterns during Ramadan. This study aims to investigate water and beverage intake and drinking patterns to help achieve water requirements during Ramadan among Indonesian adults. This is a cross-sectional study conducted during the Ramadan period from April to May 2021 (Ramadan 1442 Hijri). We used a self-administered questionnaire on drinking habits during Ramadan and utilized a 7-day fluid record (Liq.In 7) to assess water and beverage intake among participants who were managed through online procedure. There were 380 participants from five universities across Indonesia who completed the questionnaire accordingly and then analyzed it. The result shows that total water and beverage intake during Ramadan among participants was below the recommendation [1,670 (1,326–2,034) ml/day]. Among the type of beverages, water is the highest level of consumption [1,262 (983–1,666) ml/day] then followed by sugar-sweetened beverages [200 (91–350) ml/day]. We found a significant difference in water and beverages consumption between time of iftar [474 (375–590) ml/day], nighttime [574 (414–810) ml/day], and suhoor [560 (423–711) ml/day]. From this study, we found that during Ramadan the most common drinking pattern is 2-4-2, but a drinking pattern of 4-2-2 glasses (sequence of four glasses at iftar, two glasses at nighttime, two glasses at suhoor) had a significantly higher chance to adhere with the recommendation of fluid intake compared to other patterns. Therefore, based on this research on water and beverage intake, it is necessary and important to make improvements among Indonesian adults during Ramadan, and the drinking pattern of 4-2-2 glasses may help to achieve the recommended daily water consumption.

Seven decades of Ramadan intermittent fasting research: Bibliometrics analysis, global trends, and future directions

BACKGROUND AND AIMS

There is a large body of research focused on various aspects related to Ramadan intermittent fasting (RIF) and human health and disease. This study aimed to quantify the bibliometric data of RIF medical research over the past seven decades and explore these variables qualitatively via text mining analysis.

METHODS

We used the Scopus search engine to identify published articles related to RIF from inception to December 31, 2021. All types of research articles were included. Scientometric and bibliometric measures were determined using Excel, Biblioshiny, and VOSviewer. This study proposed a bibliometric and text mining method to qualitatively and quantitatively recognize the RIF research trend.

RESULTS

The Scopus search returned 1915 relevant articles. Most citations pertained to publications from the last two decades, and most publications were original research articles. These publications had received around 27,000 citations, and the 20 most prolific publishing journals had an average h-index of 112.25. More than one-third of all medical publications were in open-access journals. There was a 13-fold increase in medical research on RIF over the past few decades. We identified the 10 most prolific publishing countries, institutes, journals, and authors. We also identified five scientific hotspots of RIF scientific literature, which were: diabetes, metabolic health, public health, physiology, and maternity.

CONCLUSION

This is the first comprehensive bibliometric analysis of medical research related to RIF. The research gaps identified will shape future research directions and foster collaborative research activities toward enhanced medical nutrition research revolving around RIF.

Ramadan Fasting in Health and Disease in 2021: A Narrative Review

Introduction: The literature on the health aspects of Ramadan fasting (RF) is widely spread in many journals.

Materials and Methods: This is a narrative review of data obtained from the PubMed database (National Library of Medicine, Bethesda, Maryland, United States). We used the search term “Ramadan fasting,” and relevant records were examined. The publications are narrated thematically.

Results: The publications spanned fundamental, clinical, professional, cultural, and advocacy facets. The publications crossed conventional disciplinary lines and geographical locations and appeared in journals with different access systems. The contents are presented under the themes that emerged depending on the retrieved literature. This year basic coverage included changes in physiology and nutrition during Ramadan. However, the clinical issues included a wide range of topics. These included the impact of RF on nonalcoholic fatty liver disease and adjustments needed in endocrine replacement therapy for hypothyroidism and adrenal insufficiency. Coverage also included chronic kidney disease. The impact on maternal health, fetal well-being, and long-term effects of RF exposures were addressed in several studies. Studies in cardiovascular medicine focused on blood pressure and cardiovascular risk factors. Sports medicine and athletes' well-being received somewhat prominent coverage. The impact on renal function, particularly in patients with chronic kidney disease, was investigated by a few authors. Several groups addressed the eyes' structure and function, neurological conditions, especially headache disorders, and hematological and oncological conditions. Finally, the impact of RF on several aspects of mental health and well-being was addressed by various groups.

Conclusions: Health aspects of RF received a sustained academic interest with a broad spectrum in 2021. This narration provides an overview of the year's scholarly health-related literature on various aspects of health and disease. It should help researchers and clinicians catch up quickly with the health concerns during Ramadan.

Ramadan Intermittent Fasting Is Associated with Changes in Circulating Proprotein Convertase Subtilisin/Kexin Type 9 (PCSK9) in Metabolically Healthy Obese Subjects

Background and Objectives: Dietary modification is the principal approach to the management of hyperlipidemia in adults. Proprotein convertase subtilisin/kexin type 9 (PCSK9) is a key regulator of plasma cholesterol and a target for novel lipid-lowering pharmacotherapies. This study aimed to explore how circulating levels of PCSK9 changed during Ramadan intermittent fasting in metabolically healthy obese subjects. Materials and Methods: This cross-sectional study used convenience sampling to recruit 55 overweight and obese participants (22 females and 33 males) who observed Ramadan fasting. Body weight and composition, glucoregulatory factors, serum PCSK9 concentration, dietary intake, and physical activity were assessed 1 week before and at the end of Ramadan fasting. Results: The median (interquartile range) age was 35 (22) years, and body mass index was 30.2 (5.4). We found significant (p < 0.05) increases in serum levels of PCSK9, serum insulin, insulin resistance, and leptin at the end of Ramadan compared with pre-fasting levels. Significant (p < 0.05) reductions in body weight, waist circumference, systolic and diastolic blood pressure, total cholesterol, triglycerides, high-density lipoprotein cholesterol, and adiponectin were also observed at the end of Ramadan. Conclusions: Observing Ramadan fasting was associated with increased PCSK9 levels in metabolically healthy obese subjects. The complex relationships between PCSK9 and insulin resistance and dysregulation of adipokine secretion in relation to dietary and lifestyle modifications during Ramadan warrant further research.

Ramadan Diurnal Intermittent Fasting Is Associated With Attenuated FTO Gene Expression in Subjects With Overweight and Obesity: A Prospective Cohort Study

AIM AND BACKGROUND

A growing body of evidence supports the impact of intermittent fasting (IF) on normalizing body weight and that the interaction between body genes and environmental factors shapes human susceptibility to developing obesity. FTO gene is one of these genes with metabolic effects related to energy metabolism and body fat deposition. This research examined the changes in FTO gene expression upon Ramadan intermittent fasting (RIF) in a group of metabolically healthy subjects with overweight and obesity.

METHODS

Sixty-three (63) subjects were recruited, of which 57 (17 males and 40 females, mean age 38.4 ± 11.2 years) subjects with overweight and obesity (BMI = 29.89 ± 5.02 kg/m2were recruited and monitored before and at the end of Ramadan month), and 6 healthy subjects with normal BMI (21.4 ± 2.20 kg/m2) recruited only to standardize the reference for normal levels of FTO gene expression. In the two-time points, anthropometric, biochemical, and dietary assessments were undertaken, and FTO gene expression tests were performed using RNA extracted from the whole blood sample.

RESULTS

In contrast to normal BMI subjects, the relative gene expressions in overweight/obese were significantly decreased at the end of Ramadan (-32.30%, 95% CI-0.052 -0.981) in comparison with the pre-fasting state. Significant reductions were found in body weight, BMI, fat mass, body fat percent, hip circumference, LDL, IL-6, TNF-α (P<0.001), and in waist circumference (P<0.05), whilst HDL and IL-10 significantly increased (P<0.001) at the end of Ramadan in comparison with the pre-fasting levels. Binary logistic regression analysis for genetic expressions showed no significant association between high-energy intake, waist circumference, or obesity and FTO gene expression.

CONCLUSIONS

RIF is associated with the downregulation of the FTO gene expression in subjects with obesity, and this may explain, at least in part, its favorable metabolic effects. Hence, RIF presumably may entail a protective impact against body weight gain and its adverse metabolic-related derangements in subjects with obesity.

Does ramadan fasting affect the therapeutic and clinical outcomes of warfarin? a systematic review and meta-analysis

BACKGROUND

Warfarin's therapeutic effect is affected by many factors, including diet modifications. The impact of Ramadan fasting on warfarin is controversial. The aim of this systematic review and meta-analysis was to investigate the effect of Ramadan fasting on patients taking warfarin.

METHODS

A literature search was done in PubMed, WOS, Scopus, and Embase from inception to May 24, 2021. All relevant studies measuring the international normalized ratio (INR), time in therapeutic range (TTR), or the number of patients within therapeutic range before, during, and after Ramadan were assessed by full-text screening for achieving all of the inclusion criteria. We used the Newcastle-Ottawa Scale for quality assessment and RevMan 5.4 software for meta-analysis.

RESULTS

A total of five studies with 446 patients were included in the meta-analysis. The patients served as their own control. Our pooled analyses showed no significant difference during Ramadan compared to pre-Ramadan (MD: 0.08; 95% CI: - 0.00, 0.15; P = 0.06) and post-Ramadan (MD: - 0.00; 95% CI: - 0.14, 0.14; P = 1.00, respectively). There was only a significant increase in the risk ratio of supratherapeutic INR when comparing post-Ramadan vs. pre-Ramadan (RR: 1.69; 95% CI: 1.22, 2.33; P = 0.001). However, there was no significant risk for supratherapeutic INR during Ramadan compared to pre-Ramadan or post-Ramadan; the number of patients within the therapeutic range of INR during Ramadan compared to pre-Ramadan; and TTR during Ramadan, pre-Ramadan, and post-Ramadan.

CONCLUSION

Ramadan fasting did not affect INR level, TTR, or the number of patients within the therapeutic range before, during, and after Ramadan. However, there was a possibility of achieving a supratherapeutic INR post-Ramadan compared to pre-Ramadan. Therefore, INR monitoring and warfarin dose adjustments accordingly are recommended after Ramadan.

The effects of Ramadan intermittent fasting on liver function in healthy adults: A systematic review, meta-analysis, and meta-regression

INTRODUCTION

Growing evidence is suggestive that intermittent fasting likely to improve liver function; however, still the evidences are controversial to draw a definitive conclusion. Therefore, we conducted a systematic review and meta-analysis to estimate the effect size for changes in liver function tests (LFT) in healthy people practicing Ramadan diurnal intermittent fasting (RDIF), and to examine the impact of different covariates using subgroup analysis and meta-regression.

METHODS

Scientific databases were searched from date of inception in 1950 to the end of July 2020. The liver function tests searched and analyzed were aspartate transaminase (AST), alanine transaminase (ALT), gamma-glutamyl transferase (GGT), alkaline phosphatase (ALP), bilirubin (BLU), L-lactate dehydrogenase (LDH) and prothrombin time (PT).

RESULTS

Twenty studies (601 adult participants in total, aged 18-57 years) conducted in 10 countries between 1987 and 2020 were identified. RDIF-induced effect sizes for the LFT expressed as standardized mean difference (SMD) [95% confidence interval] were: AST (no. of studies K = 16, number of subjects N = 502, SMD = -0.257 [-0.381, -0.133], I² = 42%); ALT (K = 16, N = 502, SMD = -0.105 [-0.282, 0.07], I² = 71%); GGT (K = 2, N = 46, SMD = -0.533 [-0.842, -0.224], I² = 0%); ALP (K = 10, N = 312, SMD = -0.318 [-0.432, -0.204], I² = 0.0%); BLU (K = 10, N = 325, SMD = -0.264 [-0.520, -0.007], I² = 70.1%); LDH (K = 5, N = 145, SMD = -0.041 [-0.380, 0.298], I² = 72%); PT (K = 2, N = 74, SMD = -0.027 [-0.732, 0.678], I² = 87%).

CONCLUSION

RDIF induces significant but small (AST, ALP, BLU) to medium (GGT) positive changes on LFT, and may confer a transient, short-term protection against fatty liver disease in healthy subjects.