BRIEF REPORT

EFFECT OF RAMADAN FASTING ON CLINICAL AND BIOCHEMICAL

PARAMETERS IN HEALTHY ADULTS
H. Fakhrzadeh, MD, B. Larijani, MD, M. Sanjari, MD, R. Baradar-Jalili, MD, M.R. Amini, MD
From the Department of Endocrinology & Metabolism Research Centre, Tehran
University of Medical Sciences.

oronary heart disease (CHD) is primarily a disease

of occidental culture, being more prevalent in
populations that have adopted a high-fat, highcholesterol diet, who smoke and do not engage in
sufficient physical activity.1 The Islamic religion prescribes
fasting during Ramadan for all healthy Muslims for ostensibly
moral and spiritual reasons. It may, however, be viewed as
an effective model for CHD risk profile modulation.
The effect of Ramadan fasting on cardiovascular risk
factors is still a matter of debate. Energy intake decreases
during Ramadan, 2-5 as do weight 2-5 and body fat
percentage. 3,5 The effect of Ramadan fasting on serum lipid
profile is not so clear, however. Numerous studies report
improvements in serum lipoproteins, while a few report a
deterioration in the LDL:HDL cholesterol ratio during
Ramadan. 4 There seems to be a reduction in the number of
hospitalizations for acute coronary events during the month
of Ramadan,6 although this cannot be entirely or necessarily
attributed to the physical restrictions, which the faithful
endure during this month.
This study was performed to evaluate alterations in CHD
risk profile during the holy month of Ramadan.

Materials and Methods

Ninety-one healthy volunteers aged 20.83.1 years from
two seminary schools in Rey, south of Tehran, took part in
this study during Ramadan 2000 (1442 in the lunar calendar).
The sample consisted of 50 men (age 19.91.8 years) and
41 women (age 21.93.9 years). All participants had the same
diet and level of physical activity. Participants fasted from
sunrise to sunset for at least 25 days during Ramadan. Dietary
intake was recorded using a semi-quantitative food frequency
questionnaire on days zero and 14 of fasting. None of the
students smoked or was taking any medication at the time of
the study.
Blood samples were collected
twice: first, one week before
Correspondence to:
Ramadan after a 12-hour overnight
Dr. H. Fakhrzadeh
Fifth Floor
fast (baseline) and then on the 28th
Doctor Shariati Hospital
North Kargar Ave.,
day of Ramadan, just before sunset.
Tehran 14114
Iran
Anthropometric measures were
performed at the same time as
Accepted for publication:
January 2003
blood sampling.

223 Annals of Saudi Medicine 2003 May-July, Volume 23

Biochemical measurements took place at the laboratory

of the Endocrine and Metabolism Research Centre, affiliated
to the Tehran University of Medical Sciences.
Blood samples were centrifuged and the supernatant
plasma stored at -25C. All blood samples were analyzed in
a single batch to avoid day-to-day laboratory variation.
Glucose, total cholesterol (T-C) and triglyceride (TG) levels
were measured by auto-analyser (Hitachi 911, Bhringer
Mannheim, Germany) with standard reagents supplied by
the company. High-density lipoprotein cholesterol (HDL-C)
was measured enzymatically from the supernatant obtained
after precipitation of apolipoprotein B-containing
lipoproteins (very low-density lipoprotein [VLDL] and LDL)
by dextran sulphate and Mg++ (HDL-Cholesterol kit, Sigma
Diagnostics, USA). The intra-assay and inter-assay variation
coefficients were less than 1%. Low-density lipoprotein
(LDL-C) levels were then calculated using the Friedwald
formula (all participants had TG values <400 mg/dl).
Statistical analysis was carried out using the SPSSv10
software package. Results were expressed as meanstandard
deviation (SD). Data from before and at the end of Ramadan
were compared using the paired t-test. Relationships between
variables were evaluated using the Pearson rank correlation
test. The level of statistical significance was P<0.05.

Results
Fasting caused a significant reduction in weight and BMI
in men, and in waist circumference in women (Table 1).
Neither systolic nor diastolic blood pressure was affected by
Ramadan fasting. Fasting plasma glucose decreased
significantly in both men (P<0.0001) and women
(P<0.0001). None of the participants reported symptoms of
hypoglycaemia during fasting. There was a significant
correlation in women between fasting serum glucose and total
calorie intake (P=0.001). We detected improvements in the
lipid profile of both men and women. Serum T-C, TG and
LDL-C decreased and HDL-C increased significantly with
Ramadan fasting. There was a significant correlation between
reduced calorie intake and increased HDL-C in women
(P<0.03). Reduction of calorie intake also correlated with a
decrease in LDL-C in men (P=0.08). A significant reduction
in total daily calorie intake occurred during Ramadan in both
women and men (Table 2). The average duration of the daily
fast was 11.50.5 hours.

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Fakhrzadeh et al.
Effect of Ramadan Fasting on Clinical and Biochemical Parameters

TABLE 1. Anthropometric and biochemical parameters before and at the end of Ramadan (meanSD).
Men

Weight (kg)
Waist circumsference (cm)
BMI (kg/m2)
TG (mg/dL)
T-C (mg/dL)
LDL-C (mg/dL)
HDL-C (mg/dL)
FPG (mg/dL)
Systolic BP (mmHg)
Diastolic BP (mmHg)

Women

Baseline

28th day

P value

Baseline

28th day

P value

64.9 8.4
74.2 10.4
21.8 2.6
118.6 45.6
182.6 32.2
119.3 28.5
39.9 7.1
87.5 8.8
117.7 11.4
74.9 9.8

63.7 7.9
75.0 6.0
21.4 2.5
74.4 31.0
139.6 29.3
76.4 23.5
48.3 7.2
60.8 6.5
117.2 10.6
80.1 7.9

0.002
NS
0.004
<0.0001
0.0001
<0.0001
<0.0001
<0.0001
NS
NS

60.7 13.0
81.2 12.0
24.0 4.5
130.0 85.1
202.7 28.6
127.6 28.8
48.1 10.5
89.7 9.3
103.8 12.1
68.4 12.6

60.3 14.2
78.1 12.5
23.8 5.0
105.2 64.7
143.8 40.8
80.4 28.8
62.9 18.3
65.7 18.4
103.7 11.2
70.7 8.2

NS
<0.001
NS
<0.02
<0.0001
<0.0001
<0.0001
<0.0001
NS
NS

BMI=body mass index; TG=triglycerides; T-C=total cholesterol; LDL-C=low density lipoprotein cholesterol; HDL-C=high density
lipoprotein cholesterol; FPG=fasting plasma glucose

TABLE 2. Total daily calorie intake before and at the end of Ramadan

Total daily calorie intake

(kcal)

Baseline

Men
14th day

P value

Women
Baseline

1438.0 453.0

1212.8 549.1

<0.0001

1605.6 1176.0

Discussion
In most studies on the effects of Ramadan fasting, body
weight is either lost 7-10 or unchanged 11,12 in healthy
individuals. El-Ati et al showed increased fat oxidation and
decreased carbohydrate oxidation rates with a concomitant
decrease in plasma insulin concentration during Ramadan
fasting, as adaptive mechanisms to preserve normal body
weight and composition.11
We only detected a significant decrease in weight and
body mass index (BMI) in male participants, but did record
a significant reduction in waist circumference in female
participants. Waist circumference is a more accurate
reflection of visceral obesity, which is more strongly
associated with insulin resistance, hypertension and
dyslipidaemia, and is a better predictor than BMI of vascular
events such as stroke.13-15 Reduction of visceral adipocytes
leads to a decreased concentration of free fatty acids (FFAs)
in the portal vein due to a reduction in the rate of lipolysis,
which leads to a reduction in hepatic gluconeogenesis and
VLDL secretion.
Habbal et al showed by ambulatory monitoring that any
variation in blood pressure during the month of Ramadan is
at best minimal.16 Perk et al. showed that Ramadan fasting
does not have any undesirable effects in hypertensive patients
who continued to take their medication once a day during

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14th day

1149.8 493.5

P value

<0.005

Ramadan.17 Our participants were all normotensive, which

is to be expected given their age and, on the whole, frugal
lifestyle.
Many reports have been published on the effect of
Ramadan fasting on blood lipids in healthy individuals, with
variable findings and conclusions. Sarrafzadegan et al found
significant reductions in apoB, lipoprotein(a) [Lp(a)] and
LDL:HDL cholesterol ratio during Ramadan, while
concentrations of T-C, TG, HDL-C and LDL-C remained
unchanged in their study population.18 Akanji et al. showed
that Ramadan fasting was associated with increased levels
of apolipoprotein A1 (apoA1), and apoA1:apoB and
apoA1:HDL-C ratios in non-diabetic, hyperlipidaemic
patients. Serum concentrations of TG, T-C, LDL-C and apoB
did not increase.12
Adlouni et al found a significant increase in apoA1 and
significant decrease in apoB with Ramadan fasting and linked
it to changes in feeding behaviour during Ramadan.19 In
another report, Adlouni et al reported a significant reduction
in body weight and T-C, TG and LDL-C levels, with a
concomitant increase in HDL-C levels. These changes
persisted for one month after the end of Ramadan.17 AlHader et al showed a significant increase in TG without any
significant change in T-C after fasting in healthy
subjects.20 Maisols et al showed a striking (>30%) non-

Annals of Saudi Medicine 2003 May-July, Volume 23 224

Fakhrzadeh et al.
Effect of Ramadan Fasting on Clinical and Biochemical Parameters

pharmacologic improvement in plasma HDL-C concentration

with fasting and attributed it to eating one large meal a day
(gorging). Plasma concentrations of TG, T-C, LDL-C and
HDL-C did not change, but TC:HDL cholesterol and
LDL:HDL cholesterol ratios did decrease significantly.21
Temizhan reported that serum levels of TG, T-C, LDL-C and
VLDL-C, but not HDL-C, decreased significantly with
fasting, and found a correlation between weight loss and
decreased T-C levels.22
Animal studies have shown that starvation induces an
increased efflux of fatty acids from adipocytes, and that a
fast-induced drop in insulin levels channels FFAs into energy
production rather than cholesterol synthetic pathways.23
Total calorie intake and diet composition both affect lipid
profile through the aforementioned mechanism. While among
more affluent middle-eastern populations, average adult daily
calorie intake is approximately 3000 kcal, the corresponding
figure in communities that are either less affluent or have
adopted a frugal or ascetic lifestyle is half this amount, as is
the case in our study. This could lead to a reduction in T-C
through increased fatty acid oxidation.
Our results show a significant (P<0.05) decrease in blood
glucose levels towards the end of Ramadan. These results
are in agreement with Nomani et al.24 and Nagra et al. 25 A
common feature of these studies is that their participants were
on a low-calorie diet. In the majority of reports, however,
glucose levels did not change significantly after Ramadan
fasting.26,27 Mild fluctuations within the normal range in
serum glucose concentration have been reported.28,29 A slight
drop in serum glucose level is seen during the first few hours
of fasting, triggering a compensatory increase in hepatic
gluconeogenesis in response to decreased insulin and
increased glucagon concentration and an increase in
sympathetic activity.24,30
No study has so far been able to link Ramadan fasting
with hypoglycaemia in healthy individuals. Very few studies
have assessed the effects of Ramadan fasting on coagulation.
Sarrafzadegan et al demonstrated a slight but significant
reduction in fibrinogen and factor VII activity during
Ramadan fasting. They found an association between factor
VII activity and T-C and LDL-C levels. An association was
also shown between fibrinogen and TG, apoB and Lp(a)
levels.18 Aybak et al showed a significant increase in bleeding
and clotting times at the end of Ramadan; both were within
physiological limits, however. Platelet count remained
constant but platelet response to aggregating agents such as
ADP, collagen and adrenaline dropped towards the end of
Ramadan.31
In conclusion, Ramadan fasting is a healthy method for
improving the CHD risk profile. Since many factors can
influence the effects of Ramadan fasting on biochemical and
physiologic parameters (such as diet, daily activity, sleep
pattern, the season of fasting, socio-economic factors,

225 Annals of Saudi Medicine 2003 May-July, Volume 23

geography and climate), we recommend large-scale

coordinated multi-centre studies, with standardized
methodology, to explore the issue more extensively.

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