Religious Fasting of Muslim Patients After Metabolic and Bariatric Surgery: a Modified Delphi Consensus

Ramadan Fasting in Individuals with Metabolic Dysfunction-Associated Steatotic Liver Disease, Liver Transplant, and Bariatric Surgery: A Narrative Review

Metabolic dysfunction-associated steatotic liver disease is a growing worldwide pandemic. A limited number of studies have investigated the potential effect of Ramadan fasting on metabolic dysfunction-associated steatotic liver disease (MASLD). There is no single medication for the treatment of MASLD. There is a growing interest in dietary intervention as potential treatment for metabolic diseases including MASLD. The aim of this study was to discuss the epidemiology, pathogenesis, and risk factors of MASLD and the potential effects of Ramadan fasting on MASLD, liver transplant, and bariatric surgery. We searched PubMed and SCOPUS databases using different search terms. The literature search was based on research studies published in English from the year 2000 to the 2024. Thirty-two studies were included in this review. Ramadan fasting reduced body weight and improved lipid profile, anthropometric indices, fasting plasma glucose, plasma insulin, and inflammatory cytokines. Ramadan fasting improved risk factors of nonalcoholic fatty liver disease and might improve MASLD through weight reduction. However, further studies are needed to assess the safety and effectiveness of Ramadan fasting in liver transplant recipients and bariatric surgery.

Ramadan fasting following laparoscopic sleeve gastrectomy: a prospective online survey cohort study in Egypt

Purpose

This study aims to explore the feasibility and implications of Ramadan fasting for patients who have undergone laparoscopic sleeve gastrectomy (LSG), assessing impacts on hydration, nutrient intake, weight management, and gastrointestinal symptoms.

Methods

A prospective online survey was conducted among 218 LSG patients and 83 control individuals with obesity who had not undergone surgery. Participants were surveyed before and after Ramadan, providing data on fasting practices, hunger and satiety levels, fluid and nutrient intake, and the occurrence of gastrointestinal symptoms. Statistical analysis was used to compare outcomes between fasting and non-fasting periods and between LSG patients and control participants.

Results

A total of 70.2% of LSG patients completed the entire month of Ramadan fasting, with a significant correlation found between the duration post-surgery and the ability to fast. Fasting LSG patients reported decreased hunger, increased satiety, and significant reductions in fluid and nutrient intake during Ramadan. Weight loss was reported in 90.8% of fasting patients, with an average total weight loss of 7.2%. Gastrointestinal symptoms were mild and manageable.

Conclusion

The majority of LSG patients can successfully fast during Ramadan with appropriate precautions, including adequate fluid and protein intake. The study highlights the need for patient education and tailored nutritional guidance to ensure safe and effective fasting post-LSG. In order to fast for the entire month, patients may be advised to consider postponing surgery for a few months after Ramadan, avoid overeating during non-fasting hours, and ensure sufficient fluid consumption and protein intake during fasting.

Patient Care During Ramadan: A Narrative Review

Ramadan is the Islamic holy month when Muslims around the world fast from dawn to sunset. This 30-day pattern of intermittent diurnal fasting can have a significant physiologic impact on the body. Importantly, oral intake is forbidden during this time, and many patients do not wish to take medications. From a clinical perspective, this potentially impacts healthcare delivery and chronic disease states. Despite these important changes, awareness of individual patient practices remains limited among healthcare providers in North America, which may worsen health disparities in Muslim patients. A fundamental understanding of the cultural and physiological implications of fasting during Ramadan can improve cultural competence and patient outcomes. In this paper, we review the physiologic changes during fasting, medical exemptions to fasting, and special considerations for the care of Muslim patients with chronic conditions who may fast during Ramadan.

International survey on complications of religious fasting after metabolic and bariatric surgery

Religious fasting in Ramadan the 9th month of the lunar year is one of five pillars in Islam and is practiced for a full month every year. There may be risks with fasting in patients with a history of metabolic/bariatric surgery (MBS). There is little published evidence on the possible complications during fasting and needs stronger recommendations and guidance to minimize them. An international survey was sent to surgeons to study the types of complications occurring during religious fasting in patients with history of MBS to evaluate the risk factors to manage and prepare more evidence-based recommendations. In total, 21 centers from 11 countries participated in this survey and reported a total of 132 patients with complications occurring during religious fasting after MBS. The mean age of patients with complications was 36.65 ± 3.48 years and mean BMI was 43.12 ± 6.86 kg/m2. Mean timing of complication occurring during fasting after MBS was 14.18 months. The most common complications were upper GI (gastrointestinal) symptoms including [gastroesophageal reflux disease (GERD), abdominal pain, and dyspepsia], marginal ulcers and dumping syndrome in 24% (32/132), 8.3% (11/132) and 23% (31/132) patients respectively. Surgical management was necessary in 4.5% of patients presenting with complications (6/132) patients due to perforated marginal or peptic ulcer in Single Anastomosis Duodenoileostomy with Sleeve gastrectomy (SADI-S), one anastomosis gastric bypass (OAGB) and sleeve gastrectomy (SG), obstruction at Jejunojenostomy after Roux-en-Y gastric bypass (RYGB) (1/6) and acute cholecystitis (1/6). Patients after MBS should be advised about the risks while fasting including abdominal pain, dehydration, and peptic ulcer disease exacerbation, and a thorough review of their medications is warranted to minimize complications.

Best practice approach for redo-surgeries after sleeve gastrectomy, an expert's modified Delphi consensus

BACKGROUND

Sleeve gastrectomy (SG) is the most common metabolic and bariatric surgical (MBS) procedure worldwide. Despite the desired effect of SG on weight loss and remission of obesity-associated medical problems, there are some concerns regarding the need to do revisional/conversional surgeries after SG. This study aims to make an algorithmic clinical approach based on an expert-modified Delphi consensus regarding redo-surgeries after SG, to give bariatric and metabolic surgeons a guideline that might help for the best clinical decision.

METHODS

Forty-six recognized bariatric and metabolic surgeons from 25 different countries participated in this Delphi consensus study in two rounds to develop a consensus on redo-surgeries after SG. An agreement/disagreement ≥ 70.0% on statements was considered to indicate a consensus.

RESULTS

Consensus was reached for 62 of 72 statements and experts did not achieve consensus on 10 statements after two rounds of online voting. Most of the experts believed that multi-disciplinary team evaluation should be done in all redo-procedures after SG and there should be at least 12 months of medical and supportive management before performing redo-surgeries after SG for insufficient weight loss, weight regain, and gastroesophageal reflux disease (GERD). Also, experts agreed that in case of symptomatic GERD in the presence of adequate weight loss, medical treatment for at least 1 to 2 years is an acceptable option and agreed that Roux-en Y gastric bypass is an appropriate option in this situation. There was disagreement consensus on efficacy of omentopexy in rotation and efficacy of fundoplication in the presence of a dilated fundus and GERD.

CONCLUSION

Redo-surgeries after SG is still an important issue among bariatric and metabolic surgeons. The proper time and procedure selection for redo-surgery need careful considerations. Although multi-disciplinary team evaluation plays a key role to evaluate best options in these situations, an algorithmic clinical approach based on the expert's consensus as a guideline can help for the best clinical decision-making.

Safety and effectiveness of newer antidiabetic medications during Ramadan fasting and safety of Ramadan fasting after bariatric surgery

Background

Fasting during Ramadan is mandatory for all adult healthy Muslims. International studies found that most Muslims with diabetes mellitus fast during Ramadan. The main risk factors are hypoglycemia, Hyperglycemia, diabetic ketoacidosis, and dehydration during fasting. Therefore, stratification of the risks for severe acute diabetes complications needs to be considered for each individual and strategies personalized to advert these complications. The advent of new diabetes medications which are effective yet with a better safety profile and monitoring of blood glucose levels during the day are important to reduce the risk of untoward effects of hypoglycemia and hyperglycemia during Ramadan fasting. Here we review the safety and effectiveness of the newer diabetes medications for Ramadan fasting and whether it is safe to perform fasting after bariatric surgery.

Methods

An extensive literature search using PubMed and Google Scholar was done using different search terms. The eligible studies were 48 randomized controlled trials, prospective observational studies, and reviews from January 2008 to June 2022 which were conducted in individuals living with diabetes.

Results and Conclusions

The newer diabetes medications such as GLP-1 agonists, DPP-4 inhibitors, SGLT-2 inhibitors, and new Insulin therapy are thought to be safe and effective during fasting of Ramadan. These medications are associated with a reduction in HbA1c, body weight, systolic blood pressure and risk of hypoglycemia during Ramadan fasting. However, further studies with larger sample size are needed to confirm the efficacy and safety of these newer medications during Ramadan fasting. Individuals with Bariatric surgery should seek advice and approval to fast from the bariatric dietician, physician, and surgeon before the beginning of the month of Ramadan.

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 and Diabetes: What About Non-Fasting Patients with Diabetes?

BACKGROUND

The management of diabetes during Ramadan is well codified. International guidelines recommend avoiding fasting for patients with the risk of complications. However, during Ramadan drastic changes occur in lifestyles habits. Our study aims to evaluate the impact of the month of Ramadan on the lifestyle habits and metabolic profile of non-fasting patients with diabetes.

PATIENTS AND METHODS

This observational cross-sectional study was carried out during 3 months of Ramadan in 2018, Ramadan 2019, and Ramadan 2021. We conducted 3 consultations (before, during, and after Ramadan). Before Ramadan, we collected anthropometric and metabolic parameters, and we assessed physical activity level and dietary intake. During Ramadan, we evaluated the occurrence of complications such as hyperglycemia and hypoglycemia, as well as we assessed physical activity level, dietary intake, and the number of meals. After Ramadan re-evaluate anthropometric and metabolic parameters.

RESULTS

We included 155 patients, 93.5% had type 2 diabetes and 6.5% had type 1 diabetes. We found that glycated hemoglobin, LDL cholesterol, and Triglyceride increased significantly after Ramadan (p-value <0.001). We also found that weight, body mass index, waist circumference. Caloric intake increased significantly during Ramadan (p-value <0.001); this increase concerned 61.3% of patients. In terms of metabolic parameters, diabetes was unbalanced in 52.6% of patients, hypoglycemia occurs in 20.9% of patients, and hyperglycemia was experienced by 37% of patients during Ramadan. We found that LDL cholesterol increased in 48.4% of patients, triglycerides increased in 60.6% of patients and serum level of total cholesterol increased in 55% of patients.

CONCLUSION

Our study showed that during Ramadan risk of complications in patients with diabetes is not only related to fasting.