Ramadan Fasting Health Issues

Bahar Bastani MDBahar Bastani MDProfessor of Medicine – NephrologyProfessor of Medicine – Nephrology

Saint Louis UniversitySaint Louis University

FastingFasting

• Act of willingly abstaining from some or all food and / or drinks, for a Act of willingly abstaining from some or all food and / or drinks, for a period of time.period of time.

• Medicinal fasting: Medicinal fasting: - Purification / detoxification – HippocratesPurification / detoxification – Hippocrates- To rest the digestive systemTo rest the digestive system- A break from combating toxins that enter body with food- A break from combating toxins that enter body with food- Save energy to heal, repair and recoverSave energy to heal, repair and recover- To rest the immune system from fighting bacteria and toxinsTo rest the immune system from fighting bacteria and toxins- Detoxification, disposal of diseased and dead tissueDetoxification, disposal of diseased and dead tissue- More efficient protein and hormone synthesisMore efficient protein and hormone synthesis- Longer lifeLonger life

• There is no scientific evidence for any of the above claims.There is no scientific evidence for any of the above claims.

Demographics of the Muslim Population• Islam is the second largest religion in the world with 1.6 billion adherents

• 23% of world population.• %6 of Europe (44 mil), 4.6% of UK (2.9 mil), and 2% of US (6-8 mil)

• Ramadan Fasting = Sawm = “to refrain”• One of the 5 pillars of Islam• The 9th month in the Islamic lunar calendar• Duration of fasting varies, 11-18 hours/day, depending on the geographic

location and season• in Britain, 19 hours in summer, 10 hours in winter

• Most Muslims eat 2 meals in Ramadan Month• Before sunrise “Sahur”• After sunset “Iftar”

• Fasting is obligatory upon all Muslims, except for:• Children under the age of puberty• Pregnant, lactating or menstruating women• The old and frail• The ill• The insane• The travelling --> 50 miles in a single journey

Effects of Fasting on Glucose Metabolism

• Glucose is the primary fuel source in body and is essential for brain function.

• Metabolic changes toward the fasting state starts 8-16 hours after a meal

“post-absorptive state”.

• Eating stimulates insulin secretion --> storage of glucose as glycogen in liver and muscle.

• In the post absorptive state body turns to liver glycogen stores that last for up to 6 hours, then muscle glycogen, and then fat catabolism as a source of energy.

• When body fat storage is severely depleted (<7% of body weight in males, and <10% of body weight in females) protein catabolism starts = “STARVATION”

Effects of Fasting on Glucose Metabolism

• Fasting reduces insulin secretion and increases counter regulatory hormones (glucagon & catecholamines) --> glycogenolysis & gluconeogenesis that increase glucose release, and later increase fatty acid release and their oxidation to ketones in liver to be used as sources for energy.

• Liver storage of Glycogen (5% of its weight = 1200 calories) can provide glucose for only 5-6 hours

• First couple of days lose up to 2 Ibs per day (predominantly water loss), then ½ Ib per day.

Physiologic Adaptation to Fasting:

- Initial weight loss slows down

- Reduced metabolic rate

- Efficient utilization of the body fat reserves

- More sedentary life style

Starvation:

- Depleted carbohydrate and fat stores --> protein break down.

Poor Dietary Habits in Ramadan:

- Inappropriate diet

- Over eating at Iftar

- Insufficient sleep

- Carbohydrates: Bread/cereals/rice/fruits/sugar - Protein: fish/poultry/meat/ milk & dairy products/beans- Lipids: Polyunsaturated fats - Fibers: Vegetables/fruits

Sahur: - Complex carbohydrates – slow digesting (8 hrs): Grains, barley, whole wheat, oats, beans, lentils, whole wheat flour, unpolished rice- Protein, lipids, fibers

Iftar: - Refined carbohydrates – fast digesting (3-4 hrs): Dates (sugar, fiber, potassium, magnesium)- Protein, lipids, fibers

Major Food Groups

Effects of Fasting on Body

• Body Weight:• 137 Jordanian adults – 3 groups based on baseline body weight (over weight,

normal, under weight). All 3 groups had substantial weight loss during Ramadan fasting. The greatest weight loss was in the over weight group.

• Four out of 7 other studies confirm this observation. • Have not followed to see if the weight loss was sustained after Ramadan.

• Blood Cholesterol and Triglycerides• Eight studies, very conflicting results.

• Blood Uric Acid• Four studies show increased levels.

• Blood Glucose• 81 Tehran University students: Glucose level was reduced significantly with weight,

without change in total cholesterol and triglycerides• Other Tests

• No significant change in blood cortisol and thyroid hormones, total protein, calcium, sodium, potassium, or urea levels.

Fazel. Journal of Royal Society of Medicine. 91:260, 1998

Karamat et al. J R Soc Med. 103:139, 2010

Effects of Fasting on Cholesterol and Uric Acid

• Blood cholesterol increases with increase or decrease in body weight from normal weight.

• 30 healthy volunteers in Tunisia: Increase in total cholesterol and HDL cholesterol (20%)

• Increased total cholesterol level during fasting when there was weight loss, but not without weight loss.

• Increased blood uric acid level during fasting, correlated with the degree of weigh loss, and was prevented by increased calorie intake from dietary fat sources.

• High fat calorie intake decreases protein degradation/purine metabolism, including degradation of LDL-cholesterol receptors.

• Suggest to increase calorie intake from fat sources (poly-unsaturated fat) from recommended 30% to 36%.

Nomani. International Journal of Ramadan Fasting Research. Oct. 2002

Fasting and Diabetes

• Diabetes has a prevalence of 4% in Caucasians, 22% in Pakistani and 27% in Bangladeshi population.

• Fasting may precipitate hypoglycemia in patients on oral hypoglycemic agents or on insulin.

• Hyperglycemia with or without ketoacidosis can occur after a large Iftar.

• In over weight patients controlled on diet and oral hypoglycemic agents, weight loss from fasting would be beneficial.

• Weight was unchanged in the vast majority of type 1 and type 2 diabetics.

Fazel. J R Soc Med 91:260, 1998 / BMJ 335:613, 2007

Karamat et al. J R Soc Med. 103:139, 2010

The Epidemiology of Diabetes and RamadanEPIDIAR Study

• A retrospective population based study in 13 countries, 12,243 patients. (Algeria, Bangladesh, Egypt, India, Indonesia, Jordan, Lebanon, Malaysia, Morocco, Pakistan, Saudi Arabia, Tunisia, Turkey)

• ~9% type 1 and ~91% type 2 diabetes

• 43% of type 1 and 79% of type 2 diabetics had fasted >15 days in Ramadan

• 68% of type 1 and 61% of type 2 diabetics had received pre- Ramadan advise

• Insulin dose was unchanged in 64% of type 1&2 diabetics,

• Oral agents doses were unchanged in 75% of type 2 diabetics

• Severe hypoglycemia (requiring hospitalization) 14% vs 3% in type 1 and 3% vs 0.4% in type 2 diabetics

• Severe hyperglycemia (requiring hospitalization) 16% vs 5% in type 1 and 5% vs 1% in type 2 diabetics

Salti et al. Diabetes Care 27:2306, 2004

Fasting and Diabetes• Reduce Iftar and make Sahur the major meal.

• Oral hypoglycemic agents should be modified to a lower dose in Sahur and a regular dose at Iftar. Metformin 1/3rd with Sahur, 2/3rd with Iftar. Actos/Avandia okay.

• Fasting is not advised for patients who are prone to ketoacidosis or wide swings in blood glucose levels.

• Patients on single daily dose of insulin should be changed to twice daily dose, with a lower dose in morning. Reduce dose of long acting insulin (Lantus) by 20%, give it with Iftar.

• Consult an endocrinologist 1-2 months before Ramadan • - full check up – HbA1c, blood pressure, lipids, diabetic complications

• Exempt from fasting:• - Type 1 diabetics• - Type 2 diabetics with unstable disease• - Diabetes with complications• - Elderly with diabetes• - Pregnant women with diabetes

Fazel. J R Soc Med 91:260, 1998 / BMJ 335:613, 2007

Karamat et al. J R Soc Med. 103:139, 2010

Fasting and Cardiovascular Health

• 465 outpatients with stable heart disease had no increase in hospitalization in Ramadan.

• Hospitalization for heart failure, stroke, acute coronary events did not increase in Ramadan.

• Increased incidence of cerebral venous sinus thrombosis.

• A change in circadian variation of cardiac events:• Less at 5 – 8 am, 11% vs 19%• More at 5 – 6 pm, 11% vs 6%• More at 3 – 4 am, 11% vs 7%• More strokes between noon - 6 pm vs 6 am to noon.

Ozkan et al. J Int Med Res. 37:1988, 2009

Chong VH. Singapore Med J. 50:619, 2009

Fasting and Headaches• “The First of Ramadan Headache”

• A Saudi Hospital Staff: • Headache occurred in 41% of those who fasted versus in 8% who did not fast• More frequent in longer fasting days and towards the end of the day’s fast• Headaches were of “Tension Headache” type in 78%• Those with migraine headaches had 9.4 days of headache in Ramadan versus 3.7 days

in next month• More frequent in: Coffee/Tea drinkers (X4-5), previous headaches (X13)

• Causes:• Caffeine withdrawal• Lack of sleep• Dehydration• Hypoglycemia

• • Remedies:

• Gradual decrease in caffeine intake weeks before Ramadan• A cup of strong coffee with the Sahur• Increased fluid intake• Adequate sleep

Awada and Jumah. Headache. 39:490, 1999

Abu-Salameh et al. J Headache Pain. July 2010

Fasting and Stomach Problems

• In a university hospital in Turkey: More cases of acute upper gastrointestial bleed in Ramadan than a control month (43 versus 28 cases), and more of them had history of previous bleeding (72% versus 43%).

• More duodenal ulcers with or without bleeding in Ramadan and the month after.

• A significant increase in peptic ulcer disease and its complications – Upper gastrointestinal bleeding or peptic ulcer perforation.

Ozkan et al. J Int Med Res. 37:1988, 2009

Chong VH. Singapore Med J. 50:619, 2009

Fasting and Pregnancy

• 3 out of 4 pregnancies will coincide with Ramadan fasting.

• Many Muslim women fast during preconception, pregnancy and nursing the baby.

• Prenatal exposure to Ramadan in Arab women living in Michigan resulted in lower birth weights.

• 20% more adult disabilities, specially learning disabilities, if Ramadan coincided with early pregnancy in Uganda and Iraq.

• 1.5 time more low birth weights in mothers who fasted in first trimester.

• A higher percentage of gestational diabetes and C-Section in women who fasted during pregnancy.

• Pregnant and nursing mothers are exempt from fasting in Ramadan.

Alkandari JR et al. Journal of Sport Sciences 30 (S1): S6-S19, 2012.

Medications in Ramadan

• Many patients may change their medications during fasting.

• In a survey of 325 patients, over 60% changed the way they took their medications.

• Toxic effects were seen particularly in the elderly who took their medication once in a day, rather than the prescribed intervals.

• Drugs with longer half -life may be used. This change should be started at least 2 weeks before Ramadan to reach a steady state.

Fazel. Journal of Royal Society of Medicine. 91:260, 1998

Fasting and Other Medical Issues• “Ramadan Syndrome”, massive stomach dilatation.

• Small bowel volvulus.

• 750 Turkish Muslims surveyed: 84% felt tired or fatigued through out the day, 63% felt sleepy and irritated most of the daytime, 50% developed severe headaches.

• Reduced cognitive function in afternoon.

• Road traffic accidents increased in Saudi Arabia during Ramadan. In Morocco and Jordan road accidents and alcohol related aggression and trauma incidents decreased in Ramadan.

• Increased rate of accidents in factory workers, especially in the afternoons.

• Increased emergency department admissions for hypertension (10%) and headaches (14%), but no change in diabetes related conditions, stroke, heart attacks, or unstable angina.

• Increased incidence of retinal vein occlusion in Saudi Arabia - dehydrationFazel. Journal of Royal Society of Medicine. 91:260, 1998

Topacoglu et al. Int J Clin Pract. 59:900, 2005

Temizhan et al. Internat J Cardiol. 70:149, 1999