fasting and health issues
DESCRIPTION
My presentaion on Ramadan Fasting and Health Related Issues.TRANSCRIPT
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Ramadan Fasting Health Issues
Bahar Bastani MDBahar Bastani MDProfessor of Medicine – NephrologyProfessor of Medicine – Nephrology
Saint Louis UniversitySaint Louis University
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FastingFasting
• Act of willingly abstaining from some or all food and / or drinks, for a Act of willingly abstaining from some or all food and / or drinks, for a period of time.period of time.
• Medicinal fasting: Medicinal fasting: - Purification / detoxification – HippocratesPurification / detoxification – Hippocrates- To rest the digestive systemTo rest the digestive system- A break from combating toxins that enter body with food- A break from combating toxins that enter body with food- Save energy to heal, repair and recoverSave energy to heal, repair and recover- To rest the immune system from fighting bacteria and toxinsTo rest the immune system from fighting bacteria and toxins- Detoxification, disposal of diseased and dead tissueDetoxification, disposal of diseased and dead tissue- More efficient protein and hormone synthesisMore efficient protein and hormone synthesis- Longer lifeLonger life
• There is no scientific evidence for any of the above claims.There is no scientific evidence for any of the above claims.
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Demographics of the Muslim Population• Islam is the second largest religion in the world with 1.6 billion adherents
• 23% of world population.• %6 of Europe (44 mil), 4.6% of UK (2.9 mil), and 2% of US (6-8 mil)
• Ramadan Fasting = Sawm = “to refrain”• One of the 5 pillars of Islam• The 9th month in the Islamic lunar calendar• Duration of fasting varies, 11-18 hours/day, depending on the geographic
location and season• in Britain, 19 hours in summer, 10 hours in winter
• Most Muslims eat 2 meals in Ramadan Month• Before sunrise “Sahur”• After sunset “Iftar”
• Fasting is obligatory upon all Muslims, except for:• Children under the age of puberty• Pregnant, lactating or menstruating women• The old and frail• The ill• The insane• The travelling --> 50 miles in a single journey
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Effects of Fasting on Glucose Metabolism
• Glucose is the primary fuel source in body and is essential for brain function.
• Metabolic changes toward the fasting state starts 8-16 hours after a meal
“post-absorptive state”.
• Eating stimulates insulin secretion --> storage of glucose as glycogen in liver and muscle.
• In the post absorptive state body turns to liver glycogen stores that last for up to 6 hours, then muscle glycogen, and then fat catabolism as a source of energy.
• When body fat storage is severely depleted (<7% of body weight in males, and <10% of body weight in females) protein catabolism starts = “STARVATION”
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Effects of Fasting on Glucose Metabolism
• Fasting reduces insulin secretion and increases counter regulatory hormones (glucagon & catecholamines) --> glycogenolysis & gluconeogenesis that increase glucose release, and later increase fatty acid release and their oxidation to ketones in liver to be used as sources for energy.
• Liver storage of Glycogen (5% of its weight = 1200 calories) can provide glucose for only 5-6 hours
• First couple of days lose up to 2 Ibs per day (predominantly water loss), then ½ Ib per day.
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Physiologic Adaptation to Fasting:
- Initial weight loss slows down
- Reduced metabolic rate
- Efficient utilization of the body fat reserves
- More sedentary life style
Starvation:
- Depleted carbohydrate and fat stores --> protein break down.
Poor Dietary Habits in Ramadan:
- Inappropriate diet
- Over eating at Iftar
- Insufficient sleep
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- Carbohydrates: Bread/cereals/rice/fruits/sugar - Protein: fish/poultry/meat/ milk & dairy products/beans- Lipids: Polyunsaturated fats - Fibers: Vegetables/fruits
Sahur: - Complex carbohydrates – slow digesting (8 hrs): Grains, barley, whole wheat, oats, beans, lentils, whole wheat flour, unpolished rice- Protein, lipids, fibers
Iftar: - Refined carbohydrates – fast digesting (3-4 hrs): Dates (sugar, fiber, potassium, magnesium)- Protein, lipids, fibers
Major Food Groups
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Effects of Fasting on Body
• Body Weight:• 137 Jordanian adults – 3 groups based on baseline body weight (over weight,
normal, under weight). All 3 groups had substantial weight loss during Ramadan fasting. The greatest weight loss was in the over weight group.
• Four out of 7 other studies confirm this observation. • Have not followed to see if the weight loss was sustained after Ramadan.
• Blood Cholesterol and Triglycerides• Eight studies, very conflicting results.
• Blood Uric Acid• Four studies show increased levels.
• Blood Glucose• 81 Tehran University students: Glucose level was reduced significantly with weight,
without change in total cholesterol and triglycerides• Other Tests
• No significant change in blood cortisol and thyroid hormones, total protein, calcium, sodium, potassium, or urea levels.
Fazel. Journal of Royal Society of Medicine. 91:260, 1998
Karamat et al. J R Soc Med. 103:139, 2010
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Effects of Fasting on Cholesterol and Uric Acid
• Blood cholesterol increases with increase or decrease in body weight from normal weight.
• 30 healthy volunteers in Tunisia: Increase in total cholesterol and HDL cholesterol (20%)
• Increased total cholesterol level during fasting when there was weight loss, but not without weight loss.
• Increased blood uric acid level during fasting, correlated with the degree of weigh loss, and was prevented by increased calorie intake from dietary fat sources.
• High fat calorie intake decreases protein degradation/purine metabolism, including degradation of LDL-cholesterol receptors.
• Suggest to increase calorie intake from fat sources (poly-unsaturated fat) from recommended 30% to 36%.
Nomani. International Journal of Ramadan Fasting Research. Oct. 2002
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Fasting and Diabetes
• Diabetes has a prevalence of 4% in Caucasians, 22% in Pakistani and 27% in Bangladeshi population.
• Fasting may precipitate hypoglycemia in patients on oral hypoglycemic agents or on insulin.
• Hyperglycemia with or without ketoacidosis can occur after a large Iftar.
• In over weight patients controlled on diet and oral hypoglycemic agents, weight loss from fasting would be beneficial.
• Weight was unchanged in the vast majority of type 1 and type 2 diabetics.
Fazel. J R Soc Med 91:260, 1998 / BMJ 335:613, 2007
Karamat et al. J R Soc Med. 103:139, 2010
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The Epidemiology of Diabetes and RamadanEPIDIAR Study
• A retrospective population based study in 13 countries, 12,243 patients. (Algeria, Bangladesh, Egypt, India, Indonesia, Jordan, Lebanon, Malaysia, Morocco, Pakistan, Saudi Arabia, Tunisia, Turkey)
• ~9% type 1 and ~91% type 2 diabetes
• 43% of type 1 and 79% of type 2 diabetics had fasted >15 days in Ramadan
• 68% of type 1 and 61% of type 2 diabetics had received pre- Ramadan advise
• Insulin dose was unchanged in 64% of type 1&2 diabetics,
• Oral agents doses were unchanged in 75% of type 2 diabetics
• Severe hypoglycemia (requiring hospitalization) 14% vs 3% in type 1 and 3% vs 0.4% in type 2 diabetics
• Severe hyperglycemia (requiring hospitalization) 16% vs 5% in type 1 and 5% vs 1% in type 2 diabetics
Salti et al. Diabetes Care 27:2306, 2004
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Fasting and Diabetes• Reduce Iftar and make Sahur the major meal.
• Oral hypoglycemic agents should be modified to a lower dose in Sahur and a regular dose at Iftar. Metformin 1/3rd with Sahur, 2/3rd with Iftar. Actos/Avandia okay.
• Fasting is not advised for patients who are prone to ketoacidosis or wide swings in blood glucose levels.
• Patients on single daily dose of insulin should be changed to twice daily dose, with a lower dose in morning. Reduce dose of long acting insulin (Lantus) by 20%, give it with Iftar.
• Consult an endocrinologist 1-2 months before Ramadan • - full check up – HbA1c, blood pressure, lipids, diabetic complications
• Exempt from fasting:• - Type 1 diabetics• - Type 2 diabetics with unstable disease• - Diabetes with complications• - Elderly with diabetes• - Pregnant women with diabetes
Fazel. J R Soc Med 91:260, 1998 / BMJ 335:613, 2007
Karamat et al. J R Soc Med. 103:139, 2010
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Fasting and Cardiovascular Health
• 465 outpatients with stable heart disease had no increase in hospitalization in Ramadan.
• Hospitalization for heart failure, stroke, acute coronary events did not increase in Ramadan.
• Increased incidence of cerebral venous sinus thrombosis.
• A change in circadian variation of cardiac events:• Less at 5 – 8 am, 11% vs 19%• More at 5 – 6 pm, 11% vs 6%• More at 3 – 4 am, 11% vs 7%• More strokes between noon - 6 pm vs 6 am to noon.
Ozkan et al. J Int Med Res. 37:1988, 2009
Chong VH. Singapore Med J. 50:619, 2009
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Fasting and Headaches• “The First of Ramadan Headache”
• A Saudi Hospital Staff: • Headache occurred in 41% of those who fasted versus in 8% who did not fast• More frequent in longer fasting days and towards the end of the day’s fast• Headaches were of “Tension Headache” type in 78%• Those with migraine headaches had 9.4 days of headache in Ramadan versus 3.7 days
in next month• More frequent in: Coffee/Tea drinkers (X4-5), previous headaches (X13)
• Causes:• Caffeine withdrawal• Lack of sleep• Dehydration• Hypoglycemia
• • Remedies:
• Gradual decrease in caffeine intake weeks before Ramadan• A cup of strong coffee with the Sahur• Increased fluid intake• Adequate sleep
Awada and Jumah. Headache. 39:490, 1999
Abu-Salameh et al. J Headache Pain. July 2010
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Fasting and Stomach Problems
• In a university hospital in Turkey: More cases of acute upper gastrointestial bleed in Ramadan than a control month (43 versus 28 cases), and more of them had history of previous bleeding (72% versus 43%).
• More duodenal ulcers with or without bleeding in Ramadan and the month after.
• A significant increase in peptic ulcer disease and its complications – Upper gastrointestinal bleeding or peptic ulcer perforation.
Ozkan et al. J Int Med Res. 37:1988, 2009
Chong VH. Singapore Med J. 50:619, 2009
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Fasting and Pregnancy
• 3 out of 4 pregnancies will coincide with Ramadan fasting.
• Many Muslim women fast during preconception, pregnancy and nursing the baby.
• Prenatal exposure to Ramadan in Arab women living in Michigan resulted in lower birth weights.
• 20% more adult disabilities, specially learning disabilities, if Ramadan coincided with early pregnancy in Uganda and Iraq.
• 1.5 time more low birth weights in mothers who fasted in first trimester.
• A higher percentage of gestational diabetes and C-Section in women who fasted during pregnancy.
• Pregnant and nursing mothers are exempt from fasting in Ramadan.
Alkandari JR et al. Journal of Sport Sciences 30 (S1): S6-S19, 2012.
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Medications in Ramadan
• Many patients may change their medications during fasting.
• In a survey of 325 patients, over 60% changed the way they took their medications.
• Toxic effects were seen particularly in the elderly who took their medication once in a day, rather than the prescribed intervals.
• Drugs with longer half -life may be used. This change should be started at least 2 weeks before Ramadan to reach a steady state.
Fazel. Journal of Royal Society of Medicine. 91:260, 1998
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Fasting and Other Medical Issues• “Ramadan Syndrome”, massive stomach dilatation.
• Small bowel volvulus.
• 750 Turkish Muslims surveyed: 84% felt tired or fatigued through out the day, 63% felt sleepy and irritated most of the daytime, 50% developed severe headaches.
• Reduced cognitive function in afternoon.
• Road traffic accidents increased in Saudi Arabia during Ramadan. In Morocco and Jordan road accidents and alcohol related aggression and trauma incidents decreased in Ramadan.
• Increased rate of accidents in factory workers, especially in the afternoons.
• Increased emergency department admissions for hypertension (10%) and headaches (14%), but no change in diabetes related conditions, stroke, heart attacks, or unstable angina.
• Increased incidence of retinal vein occlusion in Saudi Arabia - dehydrationFazel. Journal of Royal Society of Medicine. 91:260, 1998
Topacoglu et al. Int J Clin Pract. 59:900, 2005
Temizhan et al. Internat J Cardiol. 70:149, 1999