|Year : 2013 | Volume
| Issue : 2 | Page : 63-68
Nutrition, energy intake- output, exercise, and fluid homeostasis during fasting in Ramadan
Mohammed A Jaleel1, Farah N Fathima2, Bushra N.F. Jaleel3
1 Department of Medicine, Bangalore Diabetes Hospital, Vasanthanagar, and AJ Diabetes Care and Polyclinic, BTM Layout, Bangalore, Karnataka, India
2 Department of Community Medicine, St. John's Medical College and Hospital, Bangalore, Karnataka, India
3 Department of Community Dentistry, Oxford Dental College, Bommanahalli, Bangalore, Karnataka, India
|Date of Web Publication||6-Jul-2013|
Mohammed A Jaleel
No. 102, Fourth Cross, First Block East, Jayanagar, Bangalore - 560011, Karnataka
Source of Support: None, Conflict of Interest: None
The month long ritual fasting undertaken by Muslims in Ramadan though intermittent in that they abstain from eating and drinking from dawn till dusk only, it is absolute during the span of fasting as they are forbidden from taking anything by mouth be it water, fruits or even oral medications. There are bound to be changes in their life style, sleep hours, physical activities, food consumption, meals frequencies, and dietary habits for different reasons. Proper management of food and fluid intake and exercise activity regulation is essential so that the spiritual fasting of Ramadan becomes an enjoyable experience free from avoidable hardships for all those who are found fit to undertake Ramadan fasting. Controlled studies are required to unravel the mysteries surrounding the complete understanding of the physiological states of satiety, hunger and fasting, and the role of both internal and external factors of orexigenic and anorexogenic nature and the scientific basis of the relative ease with which millions of Muslims the world over are able to observe the month-long Ramadan fast.
Keywords: Exercise activities, fasting, food and fluid intake, hunger, nutrition, Ramadan
|How to cite this article:|
Jaleel MA, Fathima FN, Jaleel BN. Nutrition, energy intake- output, exercise, and fluid homeostasis during fasting in Ramadan. J Med Nutr Nutraceut 2013;2:63-8
|How to cite this URL:|
Jaleel MA, Fathima FN, Jaleel BN. Nutrition, energy intake- output, exercise, and fluid homeostasis during fasting in Ramadan. J Med Nutr Nutraceut [serial online] 2013 [cited 2021 Jan 18];2:63-8. Available from: https://www.jmnn.org/text.asp?2013/2/2/63/114722
| Introduction|| |
Ramadan is the month of fasting for the Muslims the world over. They abstain totally from eating and drinking from early dawn to dusk. They may indulge in eating after dusk till early dawn. It is usual for them to reduce working/physical activities during the fasting hours in the day times. Many of them usually take evening naps and spend variable time at nights in special prayers and spend comparatively longer hours being awake at nights in the month of Ramadan. There are published reports which mention about the changes observed in life style,  sleep hours,  physical activities,  food consumption, meals frequencies, and dietary habits for different reasons in those observing Ramadan fasting. ,,
Fasting is ordained for able bodied adult Muslims. The sick and disabled can make use of the generous provisions of exemptions available and they usually refrain themselves from fasting in Ramadan. The medical personnel have an important role in giving proper advice not only about food and fluid intake but also the extent of desirable exercise to both the sick and ailing, and also to all others in general so that the ritual of fasting in Ramadan becomes an enjoyable experience for them without them unwittingly jeopardizing their health and wellbeing by ignoring the basics of nutritional management in Ramadan.
The complex relationship between the states of satiety, hunger, starvation and fasting, and the various adoptive mechanisms involved in maintaining survival and a semblance of physiological homeostasis are as yet not fully described. A systematic scientific study of the various hormonal, neural, and psychological factors which ensure generally uneventful month long fasting by millions of Muslims all over the world in different climatic conditions would be helpful in our better understanding of the phenomenon of hunger, satiety, and the way the body tackles these issues. These findings perhaps could be suitably adopted in our battle against the many primarily metabolic and nutritional disorders like overweight, obesity, and type-2 diabetes mellitus apart from situations of natural calamities, draught, famine, etc.
| Ramadan: An Inculcator of Discipline in Dietary Intake and Physical Activity|| |
Ramadan provides an excellent opportunity for inculcating dietary and physical activity discipline that could be utilized for ensuring continued corrective life style changes beyond Ramadan. A healthy normal balanced diet consumed in the usual routine suffices the dietary requirements in Ramadan in healthy normal weight individuals, and in those who are overweight Ramadan provides an excellent opportunity to shed the excess weight and practice suitable life style changes to be continued beyond the month of Ramadan.
When questioned if they can forgo their food and fluids, etc., so easily in other days when they are not fasting, the majority of Muslims would answer in negative. The only difference in Ramadan fasting and missing of meals on other days is the solemn Niyath or the religious resolve to abstain from eating, etc., for the specified period of fasting which is affirmed either verbally or silently at the beginning of the fast in Ramadan. Further scientific studies involving this Niyath or resolve to fast, and the psycho-physiological mechanisms involved in sustaining and augmenting this resolve could be helpful in better tackling of some of the life style-related disorders like obesity, hypertension, metabolic syndrome, and type-2 diabetes mellitus.
| Eating Habits in Ramadan|| |
Generally speaking, the fasting Muslims have a pre-fasting meal (Suhur) well before the dawn. They break their fast (Iftaar) soon after sunset with dates, light snacks, fruits, and fruit juices in the short span of time available for them before the obligatory sunset (Moghrib) prayers. After the Moghrib prayers usually there is a gap of about 1-2 hours before the late night (Isha) prayers followed by the Ramadan specific prayers (Taraveeh). The major post-fast meal is taken either before or after the Isha and Taraveeh prayers. As is seen they usually have three to four meals at night times and properly tuned these meals would not be different from the standard three to four meals that non-fasting persons take during the day time.
In Ramadan, abstinence from food and fluids during the day time is followed by consumption of varied amounts of food, fruits, and fluids during the time after the sunset till early dawn, i.e. the commencement of the next day's fast. Not only the eating time but also the amount and type of food so eaten is at times significantly different from that normally consumed during the other months of the year. There might be increased consumption of specially prepared foods rich in fats and protein, special additional sweet dishes, etc., with the result that there is weight gain in some in Ramadan. ,,, At the other extreme, there is a reduction in energy and nutritional intake with loss of body mass and fat due to various factors including poverty and lack of knowledge about nutritious diet and healthy food habits. ,,
| Physiological Aspects of Nutrition|| |
Nutritional demands and the way these demands are met vary depending upon the way our body is placed in a given time frame. Leaving aside the special physiological states like pregnancy, lactation, childhood, and adolescent growth periods, our body routinely is found in any of these usual five states-the fed state, the fasted state, the work state, the sleeping state, and the disease/infected/cachectic state. Putting in brief the major metabolic processes and the related hormonal controls for each of these five states could be summarized as follows.
- Fed state = glycolysis + lipogenesis, predominantly under the hormones insulin, leptin and cholecystokinin The fed state lasts about 3-4 hours from the end of the previous meal. During this phase, the body is digesting and assimilating the consumed food, generating the energy from the ingested carbohydrates and fats, and depositing the excess as stored glycogen and fat. At the end of this period starts the post-absorptive or early fasting state.
- Fasted state = lipolysis + gluconeogenesis + ketogenesis, dominated by glucagon and corticosteroids. The body now starts generating energy by metabolizing the already stored glycogen, protein and fat in the body. Glycogen stored primarily in the liver is the first to be utilized by the body to maintain satisfactory sugar levels in the blood in the post-absorptive state. The other important store of glycogen in our bodies, the skeletal muscles, do not contribute much of their glycogen for the general use but are a good source of glucose locally. Normally, at any given time the brain and CNS consume about 60% of the available glucose in the blood. Once the glycogen stores in the liver get depleted, gluconeogenesis comes into play and the liver breaks down protein and utilizes the amino acids to produce the required glucose to meet the glucose demands of the brain and other tissues. Amino acid alanine and the lactate generated by the breakdown of the proteins are efficiently utilized by the brain to produce glucose.
- Work/working state = lipolysis + glycolysis + gluconeogenesis + ketogenesis.
- Sleeping State = tissue growth and repair dominated by growth hormone and insulin like growth factor 1 (IGF-1).
- Infected/cachectic state = hypermetaboilsm; gluconeogenesis + lipolysis + proteolysis, dominated by pro-inflammatory cytokines, tumor necrosis factor- alpha (NF-α), interleukin-1 (IL-1) and interleukin-6 (IL-6), and corticosteroids.
| Physiological Aspects of Satiety and Hunger|| |
Satiety and hunger have mysteries still to be uncovered. It has been noticed that glucose-stimulated insulin secretion (GSIS) mediated through the incretins, glucose-dependent insulinotropic peptide (GIP), and glucagon-like peptide-1 (GLP-1) is reduced considerably in those who are in a fasting state.  Further during fasting there is an increase in leptin secretion with a noticeable decrease in appetite and nutrient uptake. The orexigenic intestinal hormone ghrelin secretion increases with fasting but the acylated and unacylated forms of ghrelin have been observed to exert opposing effects on GSIS. Some of the important hormonal signals involved in increasing food intake and appetite include Ghrelin, Agonti-related-protein (AgRP), Neuropeptide Y (NPY), Melanin-Concentrating Hormone (MCH), and Anandamide. Those involved in appetite suppression include Leptin, α-MSH and β-MSH, β-endorphin, Cholecystokinin (CCK), Incretins, Amylin, Pancreatic Polypeptide, PYY 3-36 , and Brain-Derived Neurotrophic Factor (BDNF).  These and other emerging studies would perhaps unfurl the mysteries surrounding the complete understanding of the physiological states of satiety, hunger and fasting, and also the scientific basis of the relative ease with which millions of Muslims the world over are able to observe the month-long Ramadan fast.
| Glycemic Index And Glycemic Load of Foods-Relevance in Ramadan|| |
Different constituents of food have varying digestion and assimilation times. Carbohydrates pass through the stomach and into the small intestine the quickest. Protein stays in the stomach longer than carbohydrates, but fats stay there the longest. So if the meal consists mostly of carbohydrates, the food would likely head into the small intestine, where nutrients are removed, more quickly than a meal that contains mostly proteins and fats. This basic fact should be kept in mind while advising the type of food for persons who fast in the month of Ramadan. The other important point to be considered is the concept of GLYCEMIC INDEX and GLYCEMIC LOAD of foods.
The glycemic index (GI) is an index of the quality content of carbohydrates in the food where as glycemic load reflects upon the quantity content of carbohydrates in the food. A rapid rise in post-meals blood sugar signals faster release of insulin from the pancreas and shortens the physiological fed state. It is advisable for those who fast to use food items of higher GI at the fast breaking time and eat foods of lower GI at the meals before the commencement of the fast.
Low carbohydrate diet with relatively more good quality protein should be advised at the Suhur meal that is traditionally eaten well before the sunrise during the Ramadan fast. This would ensure sufficient fuel for the generation of the required energy and glucose in the fasting state. At the evening fast-breaking meal (Iftaar), initially foods and drinks with high glycemic index should be advised to enable the body to replenish quickly any deficits in fluids, electrolytes, and nutrients that could have occurred due to the voluntary dietary abstinence of the day gone by. This strategy would result in satisfactory observance of fast during Ramadan and in a decrease in fat mass and an increase in muscle mass at the end of the Ramadan season.
| Fluids and Electrolytes Homeostasis in Ramadan|| |
Fluid and electrolyte homeostasis gains greater significance in tropical and sob-tropical regions especially when the Ramadan fasting season comes in summer season.
Hydration status is traditionally assessed by laboratory tests like serum osmolality and sodium concentration, blood urea nitrogen, hematocrit value, and urine osmolality. It can also be assessed by non-invasive objective measures like body mass, intake and output measurements, stool frequency and consistency, and study of vital signs like temperature, heart rate, and respiratory rate. Subjective observations such as skin turgor, thirst, and mucous membrane moisture also help in assessing the hydration status. Assessment of urine osmolality is considered to be one of the most sensitive markers of hydration status. ,
Normally, the total body water content in adults is relatively constant being the sum total of unavoidable losses in urine, feces, skin, and lungs, and the fluid intake in the form of food and drinks. Individuals are known to normally ingest more fluid than that required to meet the obligatory water losses, and the excess fluid intake is excreted by the kidneys as dilute urine. It has been reported that in situations where normal eating and drinking pattern is altered individuals become more reliant to stimuli relating to actual body water deficit and ingest significantly less fluid than usual, and that drinking of water tends to be associated with eating, and in situations where access to food is restricted, fluid intake too is often voluntarily restricted. ,
The fasting in Ramadan is in the day time and of the interrupted type, there are no restrictions on food and fluid intake at night. Hence, Ramadan fasting does not adversely affect the overnight urine volume or osmolality.  Urine samples collected in the morning and afternoon revealed that the urine volume, sodium, potassium, and total solute excretion were lower, and the urinary osmolality was higher during Ramadan indicating effective water conservation, and preservation of total near normal water and solutes in the body. 
Exercise and physical activity in Ramadan
Maintaining a healthy exercise regimen is important during Ramadan. Many individuals who fast tend to stop their usual exercises completely. Light exercises just before or after Iftaar are recommended. Exercise sessions should be of shorter duration and of lesser intensity. Strenuous exercise in the early/mid part of the day is to be avoided. It is also important to consume plenty of water and fruit juices with adequate nutritious and wholesome food during and after Iftar to ensure optimal post exercise recovery. The late night Taraveeh prayers of Ramadan performed sequentially in cycles consisting of praying in the standing, back flexing, kneeling, prostrating and sitting postures and which lasts for over one hour also helps in satisfying partly the requirements of daily exercise. Seen from a physical angle this has a combination of both isotonic and isometric muscular activity that covers most of the muscle groups in the human body.
Fasting Muslims who indulge in predominantly sedentary occupations rarely have any significant symptoms directly connected with Ramadan Fasting. But those who are engaged in physically demanding occupations in hot environment suffer from fatigue, dizziness, head ache etc., and such exposures need to be avoided or at least reduced to the minimum in those who fast in Ramadan. Chronic dehydration can be avoided by increased fluid and electrolyte use in the form of water and fruit juices during the night time.
Effects of Ramadan fasting on healthy normal individuals
It is well known that millions of Muslims scattered and living all over the world in extremely divergent and differing geo-politico-socio-economic conditions do voluntarily observe the month-long intermittent fasting in Ramadan with great zeal and enthusiasm, yet there are no authenticated reports of any significant deleterious or detrimental effects directly attributable to Ramadan fasting undertaken by healthy individuals. However, there are published report of headaches, increased irritability, day time sleepiness, increase in acid-peptic disease symptoms, decreased motor skill perception, and slight increase in road traffic injuries in Ramadan among those who fast during this month. ,,,,, These are presumed to be due to changes in their daily routine like altered sleep pattern, deprivation of caffeine and mild to moderate degrees of hypoglycemia, dehydration, etc.
Decreased physical activity coupled with excessive consumption of food and lack of exercise has been reported as the main reason for the apparent increase in weight noted among some of those who observe the Ramadan fasting.  In fact, there does not seem to be any reason for increasing the total food intake, as most people who fast are seen to reduce their daily physical activities. It is observed that in many Muslim majority countries, apart from rescheduling the work in split sessions, the official daily working hours are reduced by 2-3 hours. An adequately balanced healthy diet of similar type that is consumed in other days of the year comprising of a judicious and appropriate mix of complex carbohydrates, protein, fat, fruits and fresh vegetables with provision for ample liquids like water, fruit juices, and soups should be sufficient in Ramadan too. A healthy normal balanced diet consumed in the usual routine suffices the dietary requirements in Ramadan in healthy normal weight individuals, and in those who are overweight Ramadan provides an excellent opportunity to shed the excess weight and practice suitable life style changes to be continued beyond Ramadan. ,,,,
| Ramadan Fast- The Post-Absorptive State and not Total Starvation|| |
The day time span of Ramadan fasting, generally covers at least in the temperate regions of the earth, the early fasting or post-absorptive state which is known to last from 3 to 4 hours after the last meal up to 12 to 18 hours. After the amino-acids are utilized for glucose and energy production by gluconeogenesis or through ketogenesis, the process of lipolysis takes prominence and may continue further when the fasting and starvation states are prolonged.
Ramadan fasting starts with its Suhur (breakfast) well before the sunrise, and traditional fast-breaking at sunset and a late dinner subsequently entail a fasting of approximately 12-14 hours. It definitely does not come under the physiologist's definitions of "fasting state, long-term fasting or starvation" at which stage there would be a loss of muscle mass due to breakdown of muscle proteins, together with extreme lipolysis and ketogenesis. The fasting in the month of Ramadan, as is well known, is not absolute, in the sense the abstinence from food, fluids, caffeine is only from early dawn to dusk. The food and fluid restriction is intermittent when seen on a period span of 24 hours.
| Nutritional Guide Lines/Recommendations in Ramadan|| |
The subject of Ramadan fasting and its effects on the health and wellbeing in healthy individuals and potentially vulnerable groups has attracted sporadic attention in many circles but it needs further systematic controlled studies to understand the full medical implications of this month-long traditional intermittent state of fasting and fluid restriction so that universally acceptable recommendations and guidelines on the various issues of nutritional management in Ramadan could be formulated. The issue is further compounded by the vast differences in climate, cultural habits, dietary preferences, food habits, availability, and affordability of items of dietary consumption not only in different parts of the world but also in the different societal strata in any given geo-culturo-politico-economic scenario. Therefore, the issue needs to be area-focused. Knowledge about the prevailing ground realities assumes paramount significance in formulating such guidelines.
| Conclusion|| |
Ramadan fasting is a religious obligation for the Muslims. It aims at inculcating piety, charity, contentment, and discipline. Ramadan fasting is generally safe and beneficial for all healthy able bodied adults. Depending upon their food habits, geographical place of residence, prevailing climatic conditions, and the level of physical activities they are potentially at risk of dehydration, hypo/hyperglycemia, and weight changes. For the people of Asia and Indians in particular who are known to be at increased risk of obesity, diabetes, and related cardiovascular conditions, Ramadan season could be utilized to propagate the advantages of healthy life style with continued abstinence from tobacco use, control of weight and over/under nourishment, avoidance of sedentary behavior and maddening competition in the pursuit of the all elusive materialistic self-fulfillment, to turning toward just sufficient healthy, nutritious balanced diet, increased physical activity, and developing and maintaining a sound head and a humane heart on a disease-free body.
| References|| |
|1.||Toda M, Morimoto K. Effects of Ramadan fasting on the health of Muslims. Nihon Eiseigaku Zasshi 2000;54:592-6. |
|2.||Bahammam A. Does Ramadan fasting affect sleep? Int J Clin Pract 2006;60:1631-7. |
|3.||Chaouachi A, Leiper JB, Souissi N, Coutts AJ, Chamari K. Effects of Ramadan intermittent fasting on sports performance and training: A review. Int J Sports Physiol Perform 2009;4:419-34. |
|4.||Trepanowski JF, Bloomer RJ. The impact of religious fasting on human health. Nutr J 2010;9:57. |
|5.||Azizi F. Islamic fasting and health. Ann Nutr Metab 2010;56:273-82. |
|6.||Afifi ZE. Daily practices, study performance and health during the Ramadan fast. JR Soc Health 1997;117:231-5. |
|7.||Gharbi M, Akrout M, Zouari B. Food intake during and outside Ramadan. East Mediterr Health J 2003;9:131-40. |
|8.||Sakr AH. Fasting in Islam. J Am Diet Assoc 1975;67:17-21. |
|9.||El Ati J, Beji C, Danguir J. Increased fat oxidation during Ramadan fasting in healthy women: An adaptive mechanism for body-weight maintenance. Am J Clin Nutr 1995;62:302-7. |
|10.||Bakhotmah BA. The puzzle of self-reported weight gain in a month of fasting (Ramadan) among a cohort of Saudi families in Jeddah, Western Saudi Arabia. Nutr J 2011;10:84. |
|11.||Angel JF, Schwartz NE. Metabolic changes resulting from decreased meal frequency in adult male Muslims during the Ramadan fast. Nutr Rep Int 1975;11:29-38. |
|12.||Chandalia, H. B., Bhargav, A. and Kataria, V. (1987), Dietary pattern during Ramadan fasting and its effect on the metabolic control of diabetes. Pract Diab Int, 4: 287-90. |
|13.||Hallack MH, Nomani MZ. Body weight loss and changes in blood lipid levels in normal men on hypocaloric diets during Ramadan fasting. Am J Clin Nutr 1988;48:1197-210. |
|14.||Holness MJ, Hegazy S, Sugden MC. Signaling satiety and starvation to β-cell secretion.Curr Diabetes Rev 2011;7:336-45. |
|15.||Ziaee V, Razaei M, Ahmedinejad Z, Shaikh H, Yousefi R, Yarmohammadi L, et al. The changes of metabolic profile and weight during Ramadan fasting. Singapore Med J 2006;47:409-14. |
|16.||Leiper JB, Pitsiladis Y, Maughan RJ. Comparison of water turnover rates in men undertaking prolonged cycling exercise and sedentary men. Int J Sports Med 2001;22:181-5. |
|17.||ShirreffsSM. Markers of hydration status.EurJ ClinNutr 2003;57(Suppl 2):S6-9. |
|18.||Fitzsimons JT. Thirst. Physiol Rev 1972;52:468-561. |
|19.||De Castro JM. A microregulatory analysis of spontaneous fluid intake by humans: Evidence that the amount of liquid ingested and its timing is mainly governed by feeding. Physiol Behav 1988;43:705-14. |
|20.||Cheah H, Ch'ng SL, Husain R, Duncan NT. Effects of fasting during Ramadan on urinary excretion in Malaysian Muslims. Br J Nutr 1990;63:329-37. |
|21.||Leiper JB, Prastowo SM. Effect of fasting during Ramadan on water turnover in men living in the tropics. J Physiol 2000;528:43. |
|22.||Awada A, Al Jumah M.The first-of-Ramadan headache. Headache 1999;39:490-3. |
|23.||Kadri N, Tilane A, El Batal M, Taltit Y, Tahiri SM, Moussaoui D. Irritability during the month of Ramadan. Psychosom Med 2000;62:280-5. |
|24.||TaoudiBenchekroun M, Roky R, Toufiq J, Benaji B, Hakkou F. Epidemiological study: Chronotype and daytime sleepiness before and during Ramadan. Therapie 1999;54:567-72. |
|25.||Dönderici O, Temizhan A, Küçükbas T, Eskioglu E.Effect of Ramadan on peptic ulcer complications. Scand J Gastroenterol 1994;29:603-6. |
|26.||Ali MR, Amir T. Effects of fasting on visual flicker fusion. Percept Mot Skills 1989;69:627-31. |
|27.||Langford EJ, Ishaque MA, Fothergill J, Touguet R. The effect of the fast of Ramadan on accident and emergency attendances. J R Soc Med 1994;87:517-8. |
|28.||Salehi M, Neghab M. Effects of fasting and medium calorie balanced diet during the holy month of Ramadan on weight, BMI and some blood parameters of overweight males. Pak J Biol Sci 2007;10:968-71. |
|29.||BeltaifaL, Bouguerra R, Ben Salma C, Jabrane H, El-Khadri A, Ben Rayana MC, et al. Food intake and anthropometric and biological parameters inadult Tunisians during fasting in Ramadan. East Mediterr Health J 2002;8:603-11. |
|30.||John FT, Robert EC, Kate EM, Mohammed MK, Richard JP. Impact of caloric and dietary restriction regimens on markers of health and longevity in humans and animals: A summary of available findings. Nutr J 2011;10:107. |