Ramadan Fasting Exerts Immunomodulatory Effects: Insights from a Systematic Review

Muslim Collegiate Student-Athletes' Experience With Fasting During Ramadan While Participating in Sport

CONTEXT

As colleges and universities continue to focus on creating diverse, equitable, and inclusive environments, it is important to gain more knowledge on the experiences that Muslim student-athletes have while fasting during the month of Ramadan. Although previous researchers have investigated the physical effects of fasting on the body, little is known about the challenges or support Muslim student-athletes experience while fasting and participating in sport during Ramadan.

OBJECTIVE

To explore the experiences of Muslim collegiate student-athletes regarding fasting during Ramadan while participating in sports.

DESIGN

Qualitative research study.

SETTING

Individual video interviews.

PATIENTS OR OTHER PARTICIPANTS

Twelve Muslim collegiate student-athletes (4 women, 8 men; age = 19.9 ± 1.4 years) from 7 universities across 7 states were interviewed.

DATA COLLECTION AND ANALYSIS

A semistructured interview guide consisting of questions pertaining to the Muslim student-athletes' beliefs, challenges, experiences, and feelings was developed to gather perceptions of fasting during Ramadan while participating in sport. Data were analyzed by a multianalyst research team and coded into common themes and categories via a multiphase consensus process.

RESULTS

Four major themes emerged from the interview process: the significance of fasting and Ramadan (familial influence, religious belief, and introspection and spiritual growth), intrinsic challenges (physical challenges, mental and emotional challenges, and time constraints), extrinsic challenges (lack of available resources, knowledge and curiosity of others, and lack of understanding by others), and various types of support (sport-specific support, community support, and desired support) that affected athletes' experiences with fasting during Ramadan while participating in sport.

CONCLUSIONS

The athletic community should seek to better support Muslim student-athletes and respect the importance of fasting during Ramadan. Parties interested in the success of these athletes in sport should improve their understanding regarding Ramadan and the desired support of Muslim student-athletes 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.

Caloric Restriction: A Novel Conditioning Strategy to Improve the Survival of Ischemically Challenged Musculocutaneous Random Pattern Flaps

Caloric restriction (CR) is a cost-effective and easy-to-perform approach to counteracting surgical stress. The present study therefore evaluates the tissue-protective effects of a 30% CR in musculocutaneous flaps undergoing ischemia. For this purpose, a well-established murine dorsal skinfold chamber model, in combination with random pattern musculocutaneous flaps, was used. C57BL/6N mice were divided at random into a CR group (n = 8) and a control group with unrestricted access to standard chow (n = 8). The CR animals were subjected to a 30% reduction in caloric intake for 10 days before flap elevation. Intravital fluorescence microscopy was carried out on days 1, 3, 5, 7 and 10 after flap elevation to assess the nutritive blood perfusion, angiogenesis and flap necrosis. Subsequently, the flap tissue was harvested for additional histological and immunohistochemical analyses. The CR-treated animals exhibited a significantly higher functional capillary density and more newly formed microvessels within the flap tissue when compared to the controls; this was associated with a significantly higher flap survival rate. Immunohistochemical analyses showed a decreased invasion of myeloperoxidase-positive neutrophilic granulocytes into the flap tissue of the CR-treated mice. Moreover, the detection of cleaved caspase-3 revealed fewer cells undergoing apoptosis in the transition zone between the vital and necrotic tissue in the flaps of the CR-treated mice. These results demonstrate that a CR of 30% effectively prevents flap necrosis by maintaining microperfusion on a capillary level and inhibiting inflammation under ischemic stress. Hence, CR represents a promising novel conditioning strategy for improving the survival of musculocutaneous flaps with random pattern perfusion.

The Effect of Moderate-Intensity Physical Exercise on Some Serum Inflammation Markers and the Immune System in Rats Fed Intermittent Fasting with a High-Fat Diet

Background and Objectives: This study aimed to investigate the impact of moderate-intensity physical exercise on serum inflammation markers and the immune system in rats that were fed a high-fat diet (HFD) with intermittent fasting. Materials and Methods: A total of 48 Wistar albino male rats were included in the study and divided into eight groups, each consisting of six rats. Group 1 served as the control group (CG), receiving a standard diet. Group 2 followed the standard nutrition program with intermittent fasting (CG + IF). Group 3 underwent exercise with a standard diet (CG + E). Group 4 underwent both a standard diet with intermittent fasting and exercise (CG + IF + E). Group 5 was fed a high-fat diet (HFD). Group 6 received a high-fat diet with intermittent fasting (HFD + IF). Group 7 followed a high-fat diet with exercise (HFD + E). Group 8 underwent both a high-fat diet with intermittent fasting and exercise (HFD + IF + E). The study lasted for 8 weeks. Results: The results of the analysis show that lymphocyte cell levels in groups HFD + IF, HFD + IF, and HFD + IF + E were higher compared to groups CG-HFD (p < 0.05). Additionally, B lymphocyte and monocyte cell levels were higher in group HFD + IF + E compared to groups CG, CG + IF, and CG + IF + E, as well as CG, CG + IF, and CG + E, respectively. TNF-α levels were significantly higher in group HFD compared to the other groups. Furthermore, IL 10 levels were higher in group HFD + IF + E compared to the other groups. Conclusions: These findings indicate that moderate exercise and intermittent fasting, particularly in groups fed a high-fat diet, increased anti-inflammatory cytokine levels, and certain immune system cell counts, while decreasing pro-inflammatory cytokine levels.

Effect of Ramadan fasting on salivary IgA, serum IgA, IL-17, and IL-22 levels

Background: nutritional factors might affect the number and function of immune cells for instance the production of cytokines and immunoglobulins. Ramadan fasting is intermittent abstinence from eating and drinking for almost four weeks. Aim: The present study aimed to investigate the influence of intermittent fasting on serum IgA, salivary IgA (sIgA), interleukin (IL)-17, and IL-22 levels. Methods: 40 healthy men aged 19-29 years were evaluated before and during the fourth week of Ramadan fasting for IgA levels by the nephelometric method as well as salivary IgA (sIgA), IL-17, and IL-22 amounts using enzyme-linked immunosorbent assay (ELISA). Results: serum IgA levels reduced significantly at the end of Ramadan fasting (225.8 ± 87 vs. 196 ± 70 mg/dl) (p-value<0.001); however, sIgA amounts did not differ between before and the last week of Ramadan. Serum IL-17 reduced significantly (2.93 ± 1.51 vs. 2.17 ± 1.33 pg/ml) (p-value = 0.006) whereas IL-22 levels remained approximately unchanged. Summary: four weeks of intermittent fasting during Ramadan reduced the serum levels of IgA and IL-17 but did not affect the production of sIgA and IL-22. These findings indicate a limited impact of intermittent fasting on mucosal immunity.

Human fasting modulates macrophage function and upregulates multiple bioactive metabolites that extend lifespan in Caenorhabditis elegans: a pilot clinical study

BACKGROUND

Periodic prolonged fasting (PF) extends lifespan in model organisms and ameliorates multiple disease states both clinically and experimentally owing, in part, to its ability to modulate the immune system. However, the relationship between metabolic factors, immunity, and longevity during PF remains poorly characterized especially in humans.

OBJECTIVE

This study aimed to observe the effects of PF in human subjects on the clinical and experimental markers of metabolic and immune health and uncover underlying plasma-borne factors that may be responsible for these effects.

METHODS

In this rigorously controlled pilot study (ClinicalTrial.gov identifier, NCT03487679), 20 young males and females participated in a 3-d study protocol including assessments of 4 distinct metabolic states: 1) overnight fasted baseline state, 2) 2-h postprandial fed state, 3) 36-h fasted state, and 4) final 2-h postprandial re-fed state 12 h after the 36-h fasting period. Clinical and experimental markers of immune and metabolic health were assessed for each state along with comprehensive metabolomic profiling of participant plasma. Bioactive metabolites identified to be upregulated in circulation after 36 h of fasting were then assessed for their ability to mimic the effects of fasting in isolated human macrophage as well as the ability to extend lifespan in Caenorhabditis elegans.

RESULTS

We showed that PF robustly altered the plasma metabolome and conferred beneficial immunomodulatory effects on human macrophages. We also identified 4 bioactive metabolites that were upregulated during PF (spermidine, 1-methylnicotinamide, palmitoylethanolamide, and oleoylethanolamide) that could replicate these immunomodulatory effects. Furthermore, we found that these metabolites and their combination significantly extended the median lifespan of C. elegans by as much as 96%.

CONCLUSIONS

The results of this study reveal multiple functionalities and immunological pathways affected by PF in humans, identify candidates for the development of fasting mimetic compounds, and uncover targets for investigation in longevity research.

Aspetar clinical guidelines: Ramadan fasting and exercise for healthy individuals

Healthy adult Muslims who practice Ramadan fasting (RF) follow strict religious rules regarding their lifestyle. RF influences several parameters, including nutrition, hydration, and sleep habits, and can potentially reduce physical performance. It seems that RF prevents athletes from training and participating in competitions, and prevents the general community from engaging in physical exercise. This places practicing Muslim athletes at a competitive disadvantage. Therefore, the goal of this guide was to provide practical recommendations, based on expert panel consensus, for healthy athletes and their support staff on how to adopt appropriate behavioral, social, and psychological strategies to cope with the changes and constraints resulting from RF. The recommendations developed in this guide are not limited to prescribing appropriate exercise during the month of Ramadan (ie; schedule, frequency, intensity, duration, type of exercise, and training load), but cover different aspects of lifestyle such as nutrition, hydration, and sleep, and address psychosocial and cognitive aspects related to RF. These recommendations are intended for healthy individuals. Patients with chronic illnesses should refer to their doctor to ensure an eventual safe practice.

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.

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

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

Exploring the Effects of Energy Constraints on Performance, Body Composition, Endocrinological/Hematological Biomarkers, and Immune System among Athletes: An Overview of the Fasting State

The Ramadan fasting period (RFP) means abstaining from consuming food and/or beverages during certain hours of the day—from sunrise to sunset. Engaging in exercise and sports during the RFP leads to the lipolysis of adipose tissue and an increase in the breakdown of peripheral fat, leading to an increase in fat consumption. The effects of the RFP on functional, hematological, and metabolic parameters needs further study as existing studies have reported contradictory results. The differences in the results of various studies are due to the geographical characteristics of Muslim athletes, their specific diets, and their genetics, which explain these variations. In recent years, the attention of medical and sports researchers on the effects of the RFP and energy restrictions on bodily functions and athletic performance has increased significantly. Therefore, this brief article examines the effects of the RFP on the immune system, body composition, hematology, and the functionality of athletes during and after the RFP. We found that most sporting activities were performed during any time of the day without being affected by Ramadan fasting. Athletes were able to participate in their physical activities during fasting periods and saw few effects on their performance. Sleep and nutritional factors should be adjusted so that athletic performance is not impaired.

Ramadan Fasting as a Religious Obligation: A Qualitative Study on Opinions and Experiences of Muslim Pregnant Women about Fasting in Turkey

The aim of this study was to examine opinions and experiences of Muslim pregnant women about Ramadan fasting in Turkey. The study had a descriptive, phenomenological design and included 17 Muslim pregnant women living in Turkey. Content analysis and word cloud analysis were performed. The content analysis revealed two themes. The most frequent words in the word cloud analysis were fasting, pregnancy, Ramadan, fast, religious duty, health, observing a missed fast, relief, concern, baby, thirsty and hungry. The findings of the study showed that religious beliefs, experiences, family and society pressured the pregnant women to keep Ramadan fasts. However, due to feeling worried about their own physical and psychological health and their infants, some of the women did not go on a fast. It can be recommended that pregnant women wanting to keep their fasts should be offered information about possible risks of fasting.

Effects of Walking Football During Ramadan Fasting on Heart Rate Variability and Physical Fitness in Healthy Middle-Aged Males

This study aimed to investigate the effect of a walking football (WF) program during Ramadan fasting (RF) on heart rate variability (HRV) indices, body composition, and physical fitness in middle-aged males. Thirty-one healthy sedentary men were randomized to WF (n = 18) and control (n = 13) groups. Both groups participated in RF. The WF group were involved in a training program (small-sided games) of three sessions a week during RF. The time and frequency domains of HRV, body composition, handgrip, lumbar strength, Modified Agility Test (MAT), and 6-minute walk test (6MWT) were measured before Ramadan (BR), during Ramadan (DR), and after Ramadan (AR). We reported that RF has significantly altered some parameters of HRV DR; the mean HR decreased while the mean RR, LF, and HF increased. WF had a significant effect on HRV and mean HR DR compared with BR and AR decreased while mean RR, HF and LF increased. DR, body mass decreased in both groups, while body mass index (BMI) decreased and lean mass increased only in WF group. Lower body mass and BMI levels were reported AR only in WF group. Physical capacity improved AR, compared with BR, only in the WF group with longer distance in 6MWT, shorter time(s) in MAT, and higher lumbar strength levels. We conclude that RF increases parasympathetic system activity. WF practice during RF is safe and might improve body composition, physical fitness, autonomic cardiac function, and physical fitness in middle-aged males.

The Impacts of Ramadan Intermittent Fasting on Saliva Flow-Rate and Metabolic Data: A Systematic Review

The aim of this systematic review was to report the impacts of Ramadan intermittent fasting (RIF) on salivary flow-rate (SFR) and metabolic parameters. A thorough literature search was carried out using the databases PubMed and Scopus from their inception up to 15 July 2021. The Boolean connectors used in PubMed were (Saliva [Mesh] AND Fasting [Mesh]). The same keywords were used in Scopus. Inclusion criteria were defined using PICOS. The research included all original studies involving “healthy” adults and published in English. Methodological quality assessment was performed utilizing the Joanna Briggs Institute Critical Appraisal Tool, which allows attributing scores from 1 to 11 to the selected studies. Two authors carried out the literature search, study selection, and data extraction. Differences on issues were resolved by a third author if necessary. The systematic review protocol was registered within the “Open Science Framework” (Doi: 10.17605/OSF.IO/DE7BH). Six articles met the inclusion criteria. All studies were heterogeneous and had a high score of bias and several methodological differences. The following parameters were collected: SFR, melatonin, cortisol, glucose, immunoglobulin A (IgA), uric-acid, alkaline phosphatase (ALP), and aspartate aminotransferase (AST). The SFR decreased by 10% during Ramadan in fasting subjects. The circadian pattern of melatonin remained unchanged during Ramadan, but melatonin levels dropped significantly from baseline. The salivary cortisol levels were unchanged or increased during Ramadan. The salivary glucose levels were decreased. ALP increased significantly, whilst uric-acid and AST decreased significantly. Salivary IgA decreased during the last week of Ramadan. To conclude, there is a trend toward a decrease in SFR and the content of the majority of the biomarkers investigated, with the exception of ALP and uric-acid. These changes cannot be easily attributed to any single factor (hydration status, dietary habits, physical activity, or hygiene habits).

Systematic Review Registration: [https://osf.io/de7bh/], identifier [Doi: 10.17605/OSF.IO/DE7B].

Impact of Ramadan fasting on disease activity in patients with multiple sclerosis: a multicenter study

BACKGROUND

The safety of Ramadan fasting for Muslim patients suffering from multiple sclerosis (MS) is still a matter of debate. This work aimed to study the clinical course of MS during Ramadan fasting and to clarify the predictors of relapses and symptoms exacerbation.

METHODS

This retrospective study included 153 Muslim patients with MS. Data related to the disease course before Ramadan were obtained from patients' files, whereas data related to the disease activity during Ramadan, were collected from patients over the two months following Ramadan.

RESULTS

Patients with MS who experienced relapses, exacerbation of symptoms and development of new symptoms during Ramadan had a statistically significant longer disease duration compared to those who did not experience (P < 0.001, <0.001, 0.01 respectively). Also, patients who experienced relapses, exacerbation of symptoms and development of new symptoms during Ramadan had a statistically significant higher expanded disability status scale (EDSS) compared to those who did not experience (P <0.001, <0.001,0.01, respectively). The occurrence of relapses, exacerbation of symptoms and development of new symptoms during Ramadan, were significantly higher in patients who experienced relapses in the preceding year compared to those who did not (P= 0.002, 0.002, 0.01, respectively). Binary logistic regression revealed that each score elevation of EDSS increased the odds of relapse during Ramadan by 1.02 (P-value = 0.04). Also, each month's increase in disease duration increased the odds of relapse during Ramadan by 1.87 (P-value = 0.046).

CONCLUSION

High EDSS and long disease duration are independent predictors of relapse during Ramadan.

Innate immune remodeling by short-term intensive fasting

Previous studies have shown that long-term light or moderate fasting such as intermittent fasting can improve health and prolong lifespan. However, in humans short-term intensive fasting, a complete water-only fasting has little been studied. Here, we used multi-omics tools to evaluate the impact of short-term intensive fasting on immune function by comparison of the CD45+ leukocytes from the fasting subjects before and after 72-h fasting. Transcriptomic and proteomic profiling of CD45+ leukocytes revealed extensive expression changes, marked by higher gene upregulation than downregulation after fasting. Functional enrichment of differentially expressed genes and proteins exposed several pathways critical to metabolic and immune cell functions. Specifically, short-term intensive fasting enhanced autophagy levels through upregulation of key members involved in the upstream signals and within the autophagy machinery, whereas apoptosis was reduced by down-turning of apoptotic gene expression, thereby increasing the leukocyte viability. When focusing on specific leukocyte populations, peripheral neutrophils are noticeably increased by short-term intensive fasting. Finally, proteomic analysis of leukocytes showed that short-term intensive fasting not only increased neutrophil degranulation, but also increased cytokine secretion. Our results suggest that short-term intensive fasting boost immune function, in particular innate immune function, at least in part by remodeling leukocytes expression profile.

Ramadan Fasting during Pregnancy and Health Outcomes in Offspring: A Systematic Review

Ramadan is one of the five pillars of Islam, during which fasting is obligatory for all healthy individuals. Although pregnant women are exempt from this Islamic law, the majority nevertheless choose to fast. This review aims to identify the effects of Ramadan fasting on the offspring of Muslim mothers, particularly on fetal growth, birth indices, cognitive effects and long-term effects. A systematic literature search was conducted until March 2020 in Web of Science, Pubmed, Cochrane Library, Embase and Google Scholar. Studies were evaluated based on a pre-defined quality score ranging from 0 (low quality) to 10 (high quality), and 43 articles were included. The study quality ranged from 2 to 9 with a mean quality score of 5.4. Only 3 studies had a high quality score (>7), of which one found a lower birth weight among fasting women. Few medium quality studies found a significant negative effect on fetal growth or birth indices. The quality of articles that investigated cognitive and long-term effects was poor. The association between Ramadan fasting and health outcomes of offspring is not supported by strong evidence. To further elucidate the effects of Ramadan fasting, larger prospective and retrospective studies with novel designs are needed.

Sustainable positive effects of Ramadan intermittent fasting in rheumatoid arthritis

The short-term positive effects of intermittent fasting during the month of Ramadan on rheumatic inflammatory diseases have been previously evaluated. The objective of this study was to assess the sustainability of these effects on rheumatoid arthritis (RA) activity. This prospective study included 35 patients with RA, who observed fasting during Ramadan 2019. The disease activity was assessed and compared between three time points: T1 (6 months before the beginning of Ramadan), T2 (during the month between the 7th day of fasting and the 7th day after Ramadan), and T3 (averagely 3.4 months after fasting). The disease activity score 28 (DAS28) was used to evaluate the disease activity. After a significant decrease of all disease activity parameters between T1 and T2, a gradual increase of clinical and biological outcomes was seen between T2 and T3. Except for CRP, which was significantly higher at T3 (p = 0.02), the changes of the other disease activity parameters were not statistically significant. By reference to baseline data (T1), the decrease of ESR, DAS28 CRP, and DAS28 ESR induced after Ramadan fast was maintained until T3, with statistically significant differences. We can therefore conclude that this study has been conducted at the beginning of the fading-out of the effects of Ramadan fast, and that the duration of 3 months may be the recommended interval between fasting periods to maintain the positive effects of intermittent fasting on RA activity. Key Points • Intermittent fasting can induce a rapid improvement of rheumatoid arthritis activity. • The positive effects of this model of fasting can last up to 3 months. • The recommended interval between fasting periods may be estimated at 3 months.

Ramadan Fasting in Germany (17-18 h/Day): Effect on Cortisol and Brain-Derived Neurotrophic Factor in Association With Mood and Body Composition Parameters

Ramadan fasting (RF) is a type of diurnal intermittent fasting. Previous studies reported the benefits of RF in healthy subjects on mood and health related to quality of life (QoL). Cortisol and brain-derived neurotrophic factor (BDNF) have been shown to play a role in mood, body composition parameters, and health-related QoL. This study aimed at elucidating the mechanism of the benefit of RF, particularly cortisol and BNDF and their association with mood and QoL. Insulin growth factor-1 (IGF-1), interleukin (IL)-8, matrix metalloproteinase (MMP)-9, and myoglobin were determined. Thirty-four healthy men and women were recruited. Serum from peripheral venous blood samples was collected at five time points: 1 week before RF (T1); mid of RF (T2), last days of RF (T3), 1 week after RF (T4), and 1 month after RF (T5). The amounts of biological mediators in the serum samples were determined by enzyme-linked immunosorbent assay (ELISA) and Luminex assays. BDNF and cortisol significantly decreased at T3 (p < 0.05) and T4 (p < 0.001) compared to T1, respectively. It seems the benefits of RF for mood-related symptoms are mediated by different biological mediators, particularly cortisol and BDNF.

Dietary Intervention Impacts Immune Cell Functions and Dynamics by Inducing Metabolic Rewiring

Accumulating evidence has shown that nutrient metabolism is closely associated with the differentiation and functions of various immune cells. Cellular metabolism, including aerobic glycolysis, fatty acid oxidation, and oxidative phosphorylation, plays a key role in germinal center (GC) reaction, B-cell trafficking, and T-cell-fate decision. Furthermore, a quiescent metabolic status consolidates T-cell-dependent immunological memory. Therefore, dietary interventions such as calorie restriction, time-restricted feeding, and fasting potentially manipulate immune cell functions. For instance, intermittent fasting prevents the development of experimental autoimmune encephalomyelitis. Meanwhile, the fasting response diminishes the lymphocyte pool in gut-associated lymphoid tissue to minimize energy expenditure, leading to the attenuation of Immunoglobulin A (IgA) response. The nutritional status also influences the dynamics of several immune cell subsets. Here, we describe the current understanding of the significance of immunometabolism in the differentiation and functionality of lymphocytes and macrophages. The underlying molecular mechanisms also are discussed. These experimental observations could offer new therapeutic strategies for immunological disorders like autoimmunity.

Effects of Feed Removal during Acute Heat Stress on the Cytokine Response and Short-Term Growth Performance in Finishing Pigs

The study objective was to evaluate the effects of feed removal during acute heat stress (HS) on the cytokine response and its short-term effect on growth performance in finishing pigs. Thirty-two pigs (93.29 ± 3.14 kg initial body weight; 50% barrows and 50% gilts) were subjected to thermoneutral (TN; 23.47 ± 0.10 °C; n = 16 pigs) or HS (cycling of 25 to 36 °C; n = 16 pigs) conditions for 24 h. Within each temperature treatment, 50% of the pigs were provided with feed (AF; n = 8 pigs/temperature treatment) and 50% of the pigs had no feed access (NF; n = 8 pigs/temperature treatment). Following the 24 h temperature and feeding treatment (TF) period, all pigs had ad libitum access to feed and water and were maintained under TN conditions for 6 d. During the first 12 h of the TF period, gastrointestinal (T_GI) and skin (T_sk) temperatures were recorded every 30 min. Serum cytokines were determined at 0, 4, 8, 12, and 24 h during the TF period and on Days 3 and 6 of the post-TF period. Average daily gain (ADG) and average daily feed intake were measured on Days 1, 3, and 6 of the post-TF period. Behavioral data were collected from Days 1 to 6 of the post-TF period. Heat stress increased (p < 0.02) the T_GI and T_sk. During the post-TF period, interleukin-1α was greater (p < 0.01) in HS + NF compared to HS + AF and TN + NF pigs. From Days 1 to 2 of the post-TF period, the ADG was reduced (p < 0.01) in TN + AF compared to HS + AF, HS + NF, and TN + NF pigs. In conclusion, feed removal during an acute HS challenge did not reduce the cytokine response or improve short-term growth performance in finishing pigs.

Time-restricted eating effects on performance, immune function, and body composition in elite cyclists: a randomized controlled trial

Background

Although there is substantial interest in intermittent fasting as a dietary approach in active individuals, information regarding its effects in elite endurance athletes is currently unavailable. The present parallel randomized trial investigated the effects of a particular intermittent fasting approach, called time-restricted eating (TRE), during 4 weeks of high-level endurance training.

Methods

Sixteen elite under-23 cyclists were randomly assigned either to a TRE group or a control group (ND). The TRE group consumed 100% of its estimated daily energy needs in an 8-h time window (from 10:00 a.m. to 6:00 p.m.) whilst energy intake in the ND group was distributed in 3 meals consumed between 7:00 a.m. and 9:00 p.m. Fat and fat-free mass were estimated by bioelectrical impedance analysis and VO_2max and basal metabolism by indirect gas analyzer. In addition, blood counts, anabolic hormones (i.e. free testosterone, IGF-1) and inflammatory markers (i.e. IL-6, TNF-α) were assessed.

Results

TRE reduced body weight (− 2%; p = 0.04) and fat mass percentage (− 1.1%; p = 0.01) with no change in fat-free mass. Performance tests showed no significant differences between groups, however the peak power output/body weight ratio (PPO/BW) improved in TRE group due to weight loss (p = 0.02). Free testosterone and IGF-1 decreased significantly (p = 0.01 and p = 0.03 respectively) in TRE group. Leucocyte count decreased in ND group (p = 0.02) whilst the neutrophils-to-lymphocytes ratio (NLR) decreased significantly (p = 0.03) in TRE group.

Conclusions

Our results suggest that a TRE program with an 8-h feeding window elicits weight loss, improves body composition and increases PPO/BW in elite cyclists. TRE could also be beneficial for reducing inflammation and may have a protective effect on some components of the immune system. Overall, TRE could be considered as a component of a periodized nutrition plan in endurance athletes.

Trial registration

This trial was retrospectively registered at clinicaltrials.gov as NCT04320784 on 25 March 2020.

How Far Are We from Prescribing Fasting as Anticancer Medicine?

(1) Background: the present review provides a comprehensive and up-to date overview of the potential exploitation of fasting as an anticancer strategy. The rationale for this concept is that fasting elicits a differential stress response in the setting of unfavorable conditions, empowering the survival of normal cells, while killing cancer cells. (2) Methods: the present narrative review presents the basic aspects of the hormonal, molecular, and cellular response to fasting, focusing on the interrelationship of fasting with oxidative stress. It also presents nonclinical and clinical evidence concerning the implementation of fasting as adjuvant to chemotherapy, highlighting current challenges and future perspectives. (3) Results: there is ample nonclinical evidence indicating that fasting can mitigate the toxicity of chemotherapy and/or increase the efficacy of chemotherapy. The relevant clinical research is encouraging, albeit still in its infancy. The path forward for implementing fasting in oncology is a personalized approach, entailing counteraction of current challenges, including: (i) patient selection; (ii) fasting patterns; (iii) timeline of fasting and refeeding; (iv) validation of biomarkers for assessment of fasting; and (v) establishment of protocols for patients’ monitoring. (4) Conclusion: prescribing fasting as anticancer medicine may not be far away if large randomized clinical trials consolidate its safety and efficacy.

Fasting Ramadan During COVID-19 Pandemic: Immunomodulatory Effect

As of April 24, 2020, more than 1. 6 billion Muslims observe the holy fasting month of Ramadan worldwide. The safety of fasting of healthy adult Muslims during the COVID-19 era is debatable. In this perspective, we discuss the available scientific evidence of the advantages of fasting against COVID-19.

The efficacy of fasting regimens on health outcomes: a systematic overview

INTRODUCTION

Fasting can be defined as abstinence or reduction from food, drink, or both, for a defined period. There are many different types of fasting regimens, such as Ramadan fasting, intermittent fasting, Christian Orthodox fasting. The aim of this overview is to provide an exhaustive summary on the beneficial effects and harms associated with fasting regimens and discuss mechanisms by which this non-pharmacological approach might lead to improve human health.

EVIDENCE ACQUISITION

A systematic search was performed on MEDLINE (PubMed), Embase, Cochrane Library and CINHAL. We included systematic reviews (SRs) that report on impact of different types of fasting regimens on health. Selection of SRs, data extraction and quality assessment were undertaken in duplicate.

EVIDENCE SYNTHESIS

A total of 21 SRs were included. Cumulatively, 97 health outcomes were identified. Of them, cardiovascular risk factors were the most frequently analyzed. Ramadan fasting is associated with significant improvements in body weight and visceral lean mass, high-density lipoprotein cholesterol (HDL-c), and with reductions in low-density lipoprotein cholesterol (LDL-c) and total cholesterol (T-chol), especially in cardiac patients. Similarly, reviews on Intermittent and Orthodox fasting proved benefits of those on weight, BMI, lipidic and glucose profile, inflammatory markers.

CONCLUSIONS

Fasting regimens showed potential beneficial effects on several health indicators in adult populations. Nevertheless, evidence on some specific health dimensions (cognitive function, well-being, quality of life) is limited. Thus, in the future, further RCTs or cohort studies with good methodological quality and larger sample sizes are warranted to better understand the underlying biological mechanism and the benefits on multidimensional aspects of health.

Importance of Dietary Changes During the Coronavirus Pandemic: How to Upgrade Your Immune Response

The new coronavirus pandemic continues to spread causing further public health, social, and economic issues. The disparities in the rates of death between countries poses questions about the importance of lifestyle habits and the immune status of populations. An exploration of dietary habits and COVID-19-related death might unravel associations between these two variables. Indeed, while both nutritional excess and deficiency are associated with immunodeficiency, adequate nutrition leading to an optimally functioning immune system may be associated with better outcomes with regards to preventing infection and complications of COVID-19, as well as developing a better immune response to other pathogenic viruses and microorganisms. This article outlines the key functions of the immune system and how macronutrients, micronutrients, and metabolites from the gut microbiome can be essential in the development of an efficient immune system. In addition, the effects of intermittent fasting on the inflammatory state as well as metabolic parameters will be discussed.

Ramadan Fasting in SARS-CoV-2 (COVID-19) Pandemic

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A Prospective Clinical Trial of Prolonged Fasting in Healthy Young Males and Females-Effect on Fatigue, Sleepiness, Mood and Body Composition

Fasting during a long period (17–18 h/day) may affect daily performance. Fatigue is one of important parameters to observe for this effect. This study aimed to determine the effect of Ramadan fasting (RF)—particularly on fatigue in both young males and females. Sleepiness, mood-related symptoms (MRSs) and body composition (BC) were determined, too. Thirty-four young males and females were recruited and performed RF. They were assessed for fatigue, sleepiness, MRS and BC at T1 (one week before RF), T2 (mid of RF), T3 (last days of RF), T4 (one week after RF) and T5 (one month after RF). The assessments were done in the morning, except for fatigue and sleepiness, which were also assessed in the afternoon and evening of T1 to T5. This study observed numerous positive effects to RF. After they began fasting and compared to T1, participants experienced (1) significantly less fatigue; (2) small to large improvement of MRSs; and (3) positive changes relating to BC. RF did not appear to have a significant effect on participants’ sleepiness scores. Ultimately, this study illustrates how prolonged fasting, like RF, benefits the youth, particularly by decreasing fatigue, improving MRSs and positively impacting BC.

The potential effect of Ramadan fasting on musculoskeletal diseases: new perspectives

Ramadan, the ninth month of the Muslim lunar calendar, is a period of intermittent fasting alternated with moments of refeeding. The last decades have seen a growing number of reports that examine the potential effect of Ramadan intermittent fasting (RIF) on chronic musculoskeletal disorders. In this paper, we reviewed data that assessed the relationship of intermittent diurnal fasting during Ramadan with rheumatic diseases. Currently, recent evidence indicates that RIF may attenuate the inflammatory state by suppressing pro-inflammatory cytokine expression and reducing the body fat and the circulating levels of leukocytes. Therefore, it may be a promising non-pharmacological approach for managing the course of rheumatic inflammatory diseases. Despite differences between studies in daily fasting duration and dietary norms, there appears to be a consensus that most of the patients with rheumatoid arthritis (RA) or spondyloarthritis (SpA) who fasted Ramadan experienced relief of their symptoms. Nevertheless, further clinical trials are required to assess the effect of RIF on other musculoskeletal and bone disorders. Additionally, we evaluated the impact of RIF on chronic medication intake. Even if a few studies on this issue are available, the primary outcomes indicate that RIF does not significantly impair either compliance or tolerance to chronic medications. These findings may give some reassurance to patients with a specific fear of drug intake during this month. Key Points • Intermittent diurnal fasting during Ramadan can modulate the inflammatory status through the down-regulation of metabolic syndrome, the reduction of pro-inflammatory cytokines, and the reduction of circulating levels of leukocytes • Ramadan intermittent fasting (RIF) can effectively improve the activity of rheumatic inflammatory diseases. • Although further studies are still required, there seems no harm for patients with gout to participate in RIF. • Primary outcomes indicate that RIF may be a promising non-pharmacological intervention for the management of patients with osteoarthritis and osteoporosis.

A systematic review, meta-analysis, and meta-regression of the impact of diurnal intermittent fasting during Ramadan on glucometabolic markers in healthy subjects

AIM

Studies on the effect of Ramadan diurnal intermittent fasting (RDIF) on glucometabolic markers have yielded conflicting results. We conducted ameta-analysis to estimate the effect size for changes in glucometabolic markers in healthy, non-athletic Muslims during Ramadan, and to assess the effect of variable covariates using meta-regression.

METHODS

CINAHL, Cochrane, EBSCOhost, EMBASE, Google Scholar, ProQuest Medical, PubMed/MEDLINE, ScienceDirect, Scopus, and Web of Science databases were searched from date of inceptionto January 2020. The glucometabolic markers analyzed were: fasting glucose (FG), insulin, insulin resistance (HOMA-IR), leptin, and adiponectin.

RESULTS

We identified seventy-two studies (3134 participants in total) that were conducted in 22 countries between 1982 and 2020. RDIF-induced effect sizes for the glucometabolic markers were: FG (no. of studies K = 61, number of subjects N = 2743, Hedges'g = -0.102, 95% CI: -0.194, -0.01); serum insulin (K = 16, N = 648, Hedges'g = 0.030 95% CI: -0.165, 0.226); HOMA-IR (K = 10, N = 349, Hedges'g = -0.012, 95% CI: -0.274, 0.250); leptin (K = 13, N = 442, Hedges'g = -0.010, 95% CI: -0.243, 0.223); and adiponectin (K = 11, N = 511, Hedges'g = 0.034, 95% CI: -0.227, 0.296).

CONCLUSION

RDIF imposes no adverse metabolic impacts, and might help in improving some glucometabolic markers in healthy subjects.

Effect of Ramadan fasting on disease activity in patients with rheumatoid arthritis presenting in tertiary care hospital

BACKGROUND AND OBJECTIVE

Rheumatoid Arthritis (RA) is a common inflammatory disorder affected by various factors, including fasting. The objective of the study was to establish the effect of Ramadan fasting on DAS 28 in Rheumatoid Arthritis patients.

METHODS

In this observational cohort study done in department of rheumatology, Mayo hospital, Lahore, between May 2019 to July 2019, 240 patients were divided in fasting (n=120) and non-fasting cohort (n=120) based on their own choice. Mean DAS-28 scores before and after Ramadan was compared in both cohorts with appropriate statistical analyses.

RESULTS

Two hundred forty participants, (74 males, 166 females), were recruited. Baseline DAS of fasting group was significantly low (4.35±0.9) as compared to non-fasting group (5.07±0.91). Paired t-test showed statistically significant improvement in fasting and non-fasting groups in total and in both genders (p=0.000). Mean improvement in DAS was numerically greater and statistically significant (p=0.000) in non-fasting group (1.08±0.62) as compared to fasting ones (0.86±0.61). Post-Ramadan DAS was, however, significantly low in fasting group (3.49±0.9) versus non-fasting group (3.98±1.0) (p=0.000).

CONCLUSION

DAS 28 score decreased in both non-fasting as well as fasting patients of RA during the month of Ramadan. RA patients with moderate disease activity, who want to keep fast, can be allowed to do so without any fear of disease worsening.

Ramadan intermittent fasting and immunity: An important topic in the era of COVID-19

WITH the growing pandemic of coronavirus disease 2019 (COVID-19) caused by severe acute respiratory syndrome (SARS)-related coronavirus (SARS-CoV-2) infection, a parallel growing interest arose concerning potential preventive and adjunct therapies, dietary and lifestyle modifications, and remedies that may boost the immunity against SARS-CoV-2 infection. Furthermore, as Ramadan intermittent religious fasting that is practiced by about one and a half billion Muslims throughout the globe is coincide this year with COVID-19 pandemic, a growing debate rose concerning the expected impact of fasting during Ramadan month and the associated dietary and lifestyle behaviors on the body's immunity against the pandemic infection. Published literature was searched to find out how intermittent fasting (IF) and its model of Ramadan affect the various aspects related to the body's immunity against microbial infections. IF was found to impact immunity by changing different related elements, including oxidative stress and inflammation, metabolism, body weight, and body composition. Dietary and lifestyle modifications during Ramadan month and their impact on immunity, such as water intake and hydration status, sleep duration and timing, caloric intake and mealtime, and social and spirtual activities, were addressed. Further research is warranted to figure out how IF during ramadan affects immunity against SARS-CoV-2 infection.

Fasting mimicking diets: A literature review of their impact on inflammatory arthritis

Fasting is an act of restricting, for a certain length of time, food intake or intake of particular foods, and has been part of religious rituals for centuries. Religions such as Christianity and Islam use this practice as a form of sacrifice, self-discipline, and gratitude. However, in the past decade, fasting has penetrated the mainstream as a diet trend. There are several ways of fasting; existing fast mimicking eating methods promise accelerated weight loss, and many more benefits: lower cholesterol, prevention of type 2 diabetes and a longer lifespan. Even more, it has been proposed that fasting can downregulate the inflammatory process and potentially be used as a treatment regimen for several diseases. Here, we review the effects of fasting on immune and inflammatory pathways. Also, we present current knowledge about the role of fasting in the activity of inflammatory arthritides with a focus on rheumatoid arthritis.

Ramadan Fasting and Risk of Covid-19

Almost all religions recommend periods of fasting. Many adult Muslims fast during the holy month of Ramadan each year. Ramadan fasting as a type of intermittent fasting is a non-pharmacological intervention refining the overall health. This year, Ramadan is coincided with coronavirus disease 2019 (COVID-19) outbreak making it one of the most challenging fasting periods for Muslims in the world. There is no solid direct evidence to suggest any adverse effect of Ramadan fasting during the COVID-19 pandemic in healthy individuals. However, there are exemptions in Ramadan Fasting and those at risk of health issues should not fast. COVID-19 is a new disease and there is limited studies concerning its risk factors. The purpose of this review was shedding more light on the potential mechanisms involved in influence of practice of fasting in all forms, including Ramadan fasting on the vulnerability to infection.

Association of Ramadan Fasting and Clinical Outcomes in Patients With Myasthenia Gravis

This cohort study examines the association of Ramadan fasting with clinical outcomes in patients with myasthenia gravis.

Impact of Ramadan diurnal intermittent fasting on rheumatic diseases

INTRODUCTION

Ramadan intermittent fasting is observed by Muslims from sunrise to sunset and alternated with moments of re-feeding. The aims of this study were to assess the impact of Ramadan fasting on rheumatoid arthritis (RA) and spondyloarthritis (SpA) activity and to assess its impact on chronic medications intake in patients with rheumatic diseases.

METHODS

This prospective monocentric study included patients with RA or SpA who fasted during Ramadan of 2019. The disease activity and the managing of chronic medications were assessed and compared between two visits: the first one 6 months before starting Ramadan fasting and the second after fasting at least 7 days.

RESULTS

Fifty-six patients were included: 36 with RA (average age 57.5 ± 10.9 years) and 20 with SpA (average age 47 ± 12.6 years). In the RA group, the Disease Activity Scores (DAS) 28 ESR, and DAS 28 CRP decreased after fasting respectively from 4.3 ± 1.3 to 3.5 ± 1.4 (p < 0.001) and from 3.4 ± 1.2 to 2.9 ± 1.3 (p = 0.001). In the SpA group, Ankylosing Spondylitis Disease Activity Scores (ASDAS) ESR and ASDAS CRP decreased respectively from 2.3 ± 0.5 to 1.9 ± 0.7 (p = 0.039) and from 1.9 ± 0.5 to 1.8 ± 0.8 (p = 0.388). Fasting did not affect significantly either compliance with chronic medications or tolerance.

CONCLUSIONS

Fasting can be a possible way to induce rapid improvement of rheumatic diseases activity. In addition, patients with a specific fear of drug intake during this period can be reassured, which will enhance the adherence to treatment. Key Points • Fasting during Ramadan, the ninth month of the Islamic calendar, consists of intermittent fasting observed from sunrise to sunset. • In this set of patients, beneficial effects of intermittent fasting were demonstrated on RA activity, but were less evident in patients with SpA despite a general trend towards improvement. • Fasting did not affect significantly either compliance with chronic medications or tolerance.

New Zealand Bitter Hops Extract Reduces Hunger During a 24 h Water Only Fast

Intermittent fasting improves metabolic and cardiac health. However, increased hunger towards the end of the fasting period may affect compliance and limit its application. Our aim was to determine the effect of anorexigenic agent co-therapy on subjective ratings of appetite during the 16–24 h period of a day-long water-only intermittent fast. Thirty adult men were recruited and required to fast for 24 h from 18:00 h to 18:00 h on the same day of the week for three subsequent weeks. Treatments of either a placebo or one of two doses (high dose; HD: 250 mg or low dose; LD: 100 mg) of a bitter hops-based appetite suppressant (Amarasate®) were given twice per day at 16 and 20 h into the fast. From 18–24 h of the 24 h fast, both the HD and LD treatment groups exhibited a statistically significant (p < 0.05) > 10% reduction in hunger. Additionally, the expected lunchtime increase in hunger that was present in the placebo group (12:00 h) was absent in both the HD and LD groups. These data suggest that appetite suppressant co-therapy may be useful in reducing hunger during intermittent fasting, and show that bitter compounds may regulate appetite independently of meal timing.

Recurrent circadian fasting (RCF) improves blood pressure, biomarkers of cardiometabolic risk and regulates inflammation in men

Background

The effects of fasting on health in non-human models have been widely publicised for a long time and emerging evidence support the idea that these effects can be applicable to human practice.

Methods

In an open label longitudinal follow-up, a cohort of 78 adult men (aged 20 to 85 years) who fasted for 29 consecutive days from sunrise to sunset (16 h fasting—referred to as recurrent circadian fasting) in Pakistan, were studied. The primary outcomes of the fasting study was weight loss/recovery and the associated changes in blood pressure and circulating levels of surrogate markers linked to organ and system functions—including cardiovascular, metabolic and inflammation. Post-fasting outcomes include the regulation of physiological biomarkers.

Results

Recurrent circadian fasting with weight loss reduced blood pressure (140.6 vs. 124.2 mmHg) and markers of cardiovascular risk (~ 4-fold for resistin; triglycerides: p < 0.0001). Reduced glycemia (p < 0.0001) and the associated changes in the regulation of ketosis (β-hydroxybutyrate) were accompanied by a metabolic shift (PPARβ, osteoprotegerin), suggesting the involvement of the different physiological systems tested. Elevated orexin-A levels (p = 0.0183) in participants indicate sleep disturbance and circadian adaptation. All participants had CRP level < 2 mg/l during the fasting period and a similar trend was observed for TNFα. While most SASP molecules were decreased after the fasting period, heightened levels of IL-8 and IL-6 suggest that some inflammatory markers may be elevated by recurrent circadian fasting. Importantly, older adults reveal similar or more substantial benefits from fasting.

Conclusions

Recurrent circadian fasting is beneficial at the cardiometabolic and inflammatory levels, especially for at-risk individuals—this is contingent on compliance towards the recommended dietary behaviour, which controls carbohydrate and caloric intake. These benefits from fasting may be particularly beneficial to older adults as they often exhibit abnormal cardiovascular, metabolic and inflammatory signatures.

Electronic supplementary material

The online version of this article (10.1186/s12967-019-2007-z) contains supplementary material, which is available to authorized users.

The Safety and Impact of a Model of Intermittent, Time-Restricted Circadian Fasting ("Ramadan Fasting") on Hidradenitis Suppurativa: Insights from a Multicenter, Observational, Cross-Over, Pilot, Exploratory Study

Hidradenitis suppurativa (HS) is a chronic-relapsing and debilitating disease, which affects the components of the folliculopilosebaceous unit and severely impacts on the perceived health-related quality of life. Among the possible treatments, dietary interventions, such as fasting, have been described to positively impact on HS. However, nothing is known about the effects of circadian, intermittent fasting, such as the Ramadan fasting. A sample of 55 HS patients (24 males (43.6%) and 31 females (56.4%), mean age 39.65 ± 8.39 years, average disease duration 14.31 ± 7.03 years) was recruited in the present study. The “Severity of International Hidradenitis Suppurativa Severity Score System” (IHS4) decreased significantly from 11.00 ± 5.88 (before Ramadan) to 10.15 ± 6.45 (after Ramadan), with a mean difference of −0.85 ± 0.83 (p < 0.0001). At the univariate analyses, the improvement was associated with HS phenotype (with a prominent improvement among those with ectopic type), treatment (with the improvement being higher in patients receiving topical and systemic antibiotics compared to those treated with biologics), the “Autoinflammatory Disease Damage Index” (ADDI), and Hurley scores. At the multivariate regression analysis, only the Hurley score (regression coefficient = 0.70, p = 0.0003) was found to be an independent predictor of change in the IHS4 score after fasting. The improvement in the IHS4 score was not, however, associated with weight loss. In conclusion, the Ramadan fasting proved to be safe and effective in HS patients. Considering the small sample size and the exploratory nature of the present investigation, further studies in the field are warranted, especially longitudinal, prospective and randomized ones.

The Impacts of Ramadan Intermittent Fasting on Oxidant/Antioxidant Stress Biomarkers of Stable Chronic Obstructive Pulmonary Disease Male Patients

No prior study has evaluated the impacts of Ramadan intermittent fasting (RIF) on oxidant/antioxidant stress (OS/AOS) biomarkers in patients with chronic obstructive pulmonary disease (COPD). The aim of this study was to assess the impacts of RIF on some OS/AOS biomarkers measured in male patients with stable COPD. Fifteen COPD patients (mean age: 71 ± 6 years) fasting Ramadan in 2017 volunteered to take part in the study. Three sessions (before Ramadan [BR], end Ramadan [ER], after Ramadan [AR]) were selected. Blood samples of OS (homocysteine [μmol/L], thiobarbituric acid reactive substances [TBARS, μmol/L]) and AOS (catalase [U/ml], ceruloplasmin [g/L], superoxide dismutase [SOD, ng/ml], zinc [µmol/L], albumin [g/L]) biomarkers were consistently taken 4.5 to 2.5 hr before the iftar. Findings were analyzed by applying Friedman or Kruskal-Wallis ANOVA. Comparisons of the number of patients with high OS [high homocysteine and/or TBARS] and low AOS (low catalase and/or ceruloplasmin and/or SOD and/or zinc and/or albumin) blood values between the three sessions were performed using the Cochran test. The median ± interquartile of homocysteine (BR: 21.48 [18.98-24.49], ER: 23.15 [21.77-26.45], AR: 24.87 [21.91-37.12]), ceruloplasmin (BR: 0.27 [0.24-0.30], ER: 0.28 [0.26-0.33], AR: 0.28 [0.25-0.32]), SOD (BR: 288.00 [112.00-400.00], ER: 182.00 [152.00-386.00], AR: 234.00 [190.00-420.00]) and the mean ± SD of TBARS (BR: 5.66 ± 1.26, ER: 4.59 ± 0.78, AR: 5.29 ± 1.69), catalase (BR: 120.97 ± 54.62, ER: 106.73 ± 50.92, AR: 137.39 ± 40.88), zinc (BR: 11.85 ± 2.01, ER: 12.47 ± 2.34, AR: 12.21 ± 2.58) and albumin (BR: 39.78 ± 3.19, ER: 40.74 ± 2.26, AR: 40.56 ± 2.38) were not significantly affected by RIF. The number of patients with high OS (BR [ n = 13], ER [ n = 15], AR [ n = 14]) or low AOS (BR [ n = 12], ER [ n = 13], AR [ n = 13]) statuses were not significantly influenced by RIF. In conclusion, RIF did not induce any significant statistical or clinical changes in OS/AOS biomarkers or statuses in COPD patients.

The Impact of Intermittent Fasting (Ramadan Fasting) on Psoriatic Arthritis Disease Activity, Enthesitis, and Dactylitis: A Multicentre Study

Intermittent circadian fasting, namely Ramadan, is a common worldwide practice. Such fasting has a positive impact on psoriasis, but no data exist on its role in psoriatic arthritis (PsA)—a disease that is clearly linked to body mass index. We enrolled 37 patients (23 females and 14 males) with a mean age 43.32 ± 7.81 and they fasted for 17 h for one month in 2016. The baseline PsA characteristics were collected and 12 (32.4%) patients had peripheral arthritis, 13 (35.1%) had axial involvement, 24 (64.9%) had enthesitis, and 13 (35.1%) had dactylitis. Three patients (8.1%) were treated with methotrexate, 28 (75.7%) with TNF-α blockers, and 6 (16.2%) with IL-17 blockers. After a month of intermittent fasting, C-reactive protein (CRP) levels decreased from 14.08 ± 4.65 to 12.16 ± 4.46 (p < 0.0001), Bath Ankylosing Spondylitis Disease Activity Index (BASDAI) decreased from 2.83 ± 1.03 to 2.08 ± 0.67 (p = 0.0078), Psoriasis Area Severity Index (PASI) decreased from 7.46 ± 2.43 to 5.86 ± 2.37 (p < 0.0001), and Disease Activity index for PSoriatic Arthritis (DAPSA) decreased from 28.11 ± 4.51 to 25.76 ± 4.48 (p < 0.0001). Similarly, enthesitis improved after fasting, with Leeds Enthesitis Index (LEI) decreasing from 2.25 ± 1.11 to 1.71 ± 0.86 (p < 0.0001) and dactylitis severity score (DSS) decreasing from 9.92 ± 2.93 to 8.54 ± 2.79 (p = 0.0001). Fasting was found to be a predictor of a decrease in PsA disease activity scores (DAPSA, BASDAI, LEI, DSS) even after adjustment for weight loss. IL-17 therapy was found to be an independent predictor of decreases in LEI after fasting. These preliminary data may support the use of chronomedicine in the context of rheumatic diseases, namely PsA. Further studies are needed to support our findings.

Fasting and Its Impact on Skin Anatomy, Physiology, and Physiopathology: A Comprehensive Review of the Literature

Skin serves as the first protective line and barrier of the body. Like many other organs, skin can be affected by several disorders in response to external factors such as pathogens, ultraviolet light, and pollution, as well as endogenous alterations related to aging and/or oxidative stress disturbance. Researchers have reported new insights into how skin cells are altered in response to caloric restriction diets in mammals. One of the most well-known caloric restriction diets is the Ramadan intermittent fasting, which is a radical change in the diet plan of practitioners for the period of one lunar month. Ramadan fasting represents the fourth of the five pillars of the Islamic creed. Even though infirm individuals are waived to take part in this religious duty, patients with various health problems, including those with different skin disorders, might choose to share this event with peers and family members. No standardized protocols or guidelines exist, however, to advise their physicians on the proper management of their patients' condition during fasting. With an increasing Muslim population living in Western countries, this topic has started to draw substantial attention, not only of Middle-Eastern physicians, but also of clinicians in the West. For this purpose, we carried out a comprehensive overview on the topic. Our main findings are that: (1) there is a strong need for evidence-based suggestions and guidance. Literature on the impact of the Ramadan fasting, as well as of other kinds of fasting, on skin diseases is scarce and of poor quality, as well as the information available from the Internet; (2) patients willing to fast should be advised about the importance of taking proper treatments or consider alternative options including administration of trans-dermal/topical drugs, as they are permitted during daylight hours. Further, non-compliance has important, clinical and economic implications for an effective patient management.

How do pregnant and lactating women, and young children, experience religious food restriction at the community level? A qualitative study of fasting traditions and feeding behaviors in four regions of Ethiopia

Maternal and child feeding behaviors are often rooted in family and sociocultural context, making these an important point of inquiry for improving nutrition and health over the life course. The present study explored the practice of fasting during religious periods in relation to eating patterns of pregnant and lactating women and young children in four regions of Ethiopia, a nation which has experienced rapid economic growth and marked improvement in health and nutrition outcomes over the last two decades. Qualitative data collection and analysis at community level illustrated conflicting areas of understanding and practice related to diets of children and pregnant and lactating women during fasting times, potentially leading to gaps in nutrition. Community participants described different understandings of fasting requirements for these vulnerable populations and associated social norms and doxa, not always in accordance with religious texts or published guidance. Useful behavior change strategies may be developed through these results to address the potential barriers to appropriate feeding patterns for pregnant and lactating women and young children in Ethiopia. This will include continuing to work with communities and religious leaders to clarify that religious doctrine promotes improved nutrition outcomes.

Higher rate of hyperglycemia than hypoglycemia during Ramadan fasting in patients with uncontrolled type 1 diabetes: Insight from continuous glucose monitoring system

BACKGROUND

Patients with uncontrolled type 1 diabetes mellitus (T1DM) are at a high risk for Ramadan fasting and are exempt from fasting; however, most still insist on fasting. The aim of this study was to examine glucose level fluctuations in those patients during Ramadan fasting using a real-time continuous glucose monitoring system (RT-CGMS).

METHODS

This pilot study involved adult patients with uncontrolled T1DM (HbA1c > 7%) who insisted on fasting during Ramadan in 2014 from Maternity and Children's Hospital, Medina, Saudi Arabia. A Medtronic RT-CGMS was used to monitor the participants' glucose levels for 3 consecutive days during fasting.

RESULTS

The study included 22 patients (mean age 22 ± 6 years, duration of diabetes 10.9 ± 7.2 years, HbA1c level 9.3 ± 1.2). All participants were using the basal-bolus insulin regimen, except for one patient who was on an insulin pump. Sensor glucose (SG) profiles typically followed a pattern that was characterized by an exaggerated increase after iftar, which was sustained overnight, and a second rapid rise after suhoor, with a prolonged glucose decay over the daylight hours. The average SG was 199 ± 104.1 mg/dl, which was lower during fasting 188.4 ± 103.41 mg/dl than during the eating hours 212.5 ± 103.51 mg/dl (P = 0.00). There was a higher rate of hyperglycemia (48%) than hypoglycemia (10%).

CONCLUSIONS

Patients with uncontrolled T1DM who fasted during Ramadan experienced a wide fluctuation of glucose levels between fasting and eating hours, exhibiting a greater tendency toward hyperglycemia. The long-term effects for this finding are not known and warrant further investigation.