Effect of Ramadan fasting on anthropometric parameters and food consumption in 276 type 2 diabetic obese women

AIM: To assess the effect of Ramadan fasting on body weight and food consumption in type 2 diabetic obese women. MATERIALS AND METHODS: A total of 276 outpatient women receiving oral antidiabetic drugs (OADs) (BMI = 34.63 – 3.29 kg/m 2 ), aged 49 (–6 years), were selected. The study was carried out over three periods - before (T1: prefasting), during (T2: fasting), and after (T3: postfasting) Ramadan in three towns located in the northwestern region of Algeria. During the course of 3 days, the daily food intake and anthropometric parameters weight, height, waist and hip circumferences, body mass index (BMI), and waist-hip ratio (WHR) were recorded. A one-way repeated measures ANOVA test was used to compare the groups. RESULTS: The main effect of fasting during Ramadan was a signi (cid:222) cant weight loss ((cid:150)3.12 kg i.e. 3.70%; P < 0.01), a decrease in meal frequency (2.2 – 0.3 vs. 4.3 – 0.4) as well as in energy intake (1488 – 118 vs.1823 – 262 Kcal/d) and an important increase in dietary fat consumption (35.84 vs. 25.36%), especially the saturated one (231Kca/d i.e. 43.25%) of total fat, dietary cholesterol – 121 vs. 221 – mg/d), and polyunsaturated fatty acids (PUFA). Except in three cases, there were frequent hypoglycaemic observed among the participants. CONCLUSIONS: Fasting during the of Ramadan causes weight loss and decrease in calorie intake, which is correlated with a decrease in However, more foods rich in fat A decrease in daily calorie intake has been seen as one of the advantages in Ramadan fasting. [5,11-17] Some authors [15] observed a decrease in energy intake (103 Kcal/d), though not statistically signi (cid:222) cant, which is correlated with meal frequency. [13] However, in another study, [18] the total daily energy intake (TEI) remained unchanged. Our study investigated the e ﬀ ect of fasting, during Ramadan, on some anthropometric parameters, and assessed food consumption among a group of obese women with type 2 diabetes mellitus (T2DM).


AIM:
To assess the effect of Ramadan fasting on body weight and food consumption in type 2 diabetic obese women. MATERIALS AND METHODS: A total of 276 outpatient women receiving oral antidiabetic drugs (OADs) (BMI = 34.63 ± 3.29 kg/m 2 ), aged 49 (±6 years), were selected. The study was carried out over three periods -before (T1: prefasting), during (T2: fasting), and after (T3: postfasting) Ramadanin three towns located in the northwestern region of Algeria. During the course of 3 days, the daily food intake and anthropometric parameters weight, height, waist and hip circumferences, body mass index (BMI), and waist-hip ratio (WHR) were recorded. A one-way repeated measures ANOVA test was used to compare the groups. RESULTS: The main effect of fasting during Ramadan was a signiÞ cant weight loss (-3.12 kg i.e. 3.70%; P < 0.01), a decrease in meal frequency (2.2 ± 0.3 vs. 4.3 ± 0.4) as well as in energy intake (1488 ± 118 vs.1823 ± 262 Kcal/d) and an important increase in dietary fat consumption (35.84 vs. 25.36%), especially the saturated one (231Kca/d i.e. 43.25%) of total fat, dietary cholesterol (392 ± 121 vs. 221 ± 73 mg/d), and polyunsaturated fatty acids (PUFA). Except in three cases, there were no frequent hypoglycaemic episodes observed among the participants. CONCLUSIONS: Fasting during the month of Ramadan causes weight loss and decrease in calorie intake, which is correlated with a decrease in meal frequency. However, more foods rich in fat and dietary cholesterol were consumed during this period. The latter could constitute a high risk for diabetics who are fasting, in particular when medication advice and/ or health care control are insufÞ cient or ignored.

Introduction
During the sacred month of Ramadan, people who fast neither eat nor drink from dawn to sunset. Among disabled individuals with acute or chronic diseases, certain diabetics can be exempted from fasting. Many people with diabetes still prefer to fast, without medical guidance, exposing themselves to certain health risks as a direct consequence of fasting or because of a change in food and frequency of medication intake. Although the beneÞ t of experimental supplemented fasting has been well demonstrated, in diabetics, the consequential eff ects of fasting during Ramadan remain oft en controversial. [1][2][3][4] Modifying eating habits during Ramadan fasting and then signiÞ cantly increasing one's intake aft er breaking the fast, could unbalance the metabolism of patients with diabetes and inß uence their nutritional intake and their anthropometric parameters. [5][6][7][8][9][10][11][12][13] Concerning diet during Ramadan, people usually eat two meals, one before dawn (Sahur) and one just aft er sunset (Ift ar). Few studies have assessed the food intake among type 2 diabetics and we Þ nd conß icting results with those reported in. [14] A decrease in daily calorie intake has been seen as one of the advantages in Ramadan fasting. [5,[11][12][13][14][15][16][17] Some authors [15] observed a decrease in energy intake (103 Kcal/d), though not statistically signiÞ cant, which is correlated with meal frequency. [13] However, in another study, [18] the total daily energy intake (TEI) remained unchanged. Our study investigated the eff ect of fasting, during Ramadan, on some anthropometric parameters, and assessed food consumption among a group of obese women with type 2 diabetes mellitus (T2DM).

Patients and study design
The study was undertaken during Ramadan of 2004 in three towns located in the north-western region of Algeria (Saïda: Diabetes Centre, Sidi-Bel-Abbès: Petit-Vichy Diabetes Centre and University Hospital, and Oran: Hospital University). The volunteer outpatients who wanted to fast during Ramadan consisted of 276 type 2 diabetic obese women (BMI>30), aged 49 (±6) years, whose diabetes was identiÞ ed 4 (±2) years ago and who presented no degenerative complications or hypertension. We focused our choice on diabetic and obese people because the prevalence of diabetes is primarily att ributable to the rising rate of overweight and obesity. [19] Subjects were chosen if they had had diabetes for less than 5 years, because those who were preselected with over 5 years of diabetes presented some degenerative complications and, in this fact, were excluded. In addition, women were chosen for this study with the knowledge that another study would be done with male subjects. Throughout the study, diabetics received oral antidiabetic drugs (OADs); metformin: Glucophage ® 850mg, alone as monotherapy or associated with glimepiride: Amarel ® 3 or 4 mg as bitherapy. During fasting days, 160 patients were on single hypoglycaemic therapy (metformin) twice daily; the Þ rst one was taken at dawn and the second one at sunset (when fast was broken). The other 116 patients on bitherapy (metformin and glimepiride) once daily before the Þ rst meal and with the same dose, that is metformin 850 mg, glimepiride 3 or 4 mg. None of the diabetics, who gave their writt en consent following the explanation of the study protocol according to Djillali Liabès university ethics committ ee, followed any special restricted diet or smoked, but some guidance on how to manage medication during Ramadan was given. Physical activity, before and during Ramadan, was considered as moderate and restricted to housework for the majority of patients. Finally, women who were pregnant or breastfeeding were excluded from the study.

Methods
The study lasted for three months and was scheduled over three periods: one month before Ramadan (T1: prefasting), during the month of Ramadan (T2: fasting at the middle), and one month after Ramadan (T3: postfasting). The protocol included a questionnaire in the form of an individual face-to-face interview. The objective of the interview was to gather sociodemographic data, current treatment, body weight status, lifestyle change during Ramadan and frequency of hypo or hyperglycaemia. Three measurements were taken and then averaged for weight and height. Body weight was measured, always in the morning, to the nearest 0.1 kg, with an electronic balance (SECA ® -Germany; SECA 731 Sauna: Capacity: 150 Kg/Graduations: 1.000 g), with the participants wearing light clothing.
The BMI was deÞ ned as follows: BMI (kg/m 2 ) = weight (kg)/height 2 (m 2 ). Waist-hip ratio (WHR) was determined by measuring the waist circumference (WC) at the narrowest part of the torso and the hip circumference in a horizontal plane at the level of the maximal extension of the butt ocks. All anthropometric parameters were noted throughout the three periods.
The nutrient intake was evaluated by means of a 3-days food record. To this end, all of the patients were instructed on how to record their daily dietary intake. Food quantities were calculated using household measurements (plate, glass, slice, and bowl) during the three periods. Then individual records were reviewed, and the nutrient calculations were carried out using the USDA's food composition table. [20] Energy intake and diet composition nutrients were calculated with the Nutrinux v1.0 © soft ware. Concerning metabolic control, blood samples were drawn aft er 12 h of overnight fasting and were collected over the three periods. The measure of fasting serum glucose (FSG), glycosylated haemoglobin (HbA1c), and lipid components (total cholesterol, triglycerides, HDL-cholesterol, LDL-cholesterol, apoA-I, and apoB) were used to present the biological results for the present study (data not shown).

Statistical analysis
Values are expressed as mean ± SD. Analyses were performed using SPSS (version 15.0). Group means were compared using one-way repeated measures ANOVA test. Linear regression analysis was performed for determining the contribution of "Ift ar" in the total energy intake (TEI). Additional correlations were made to determine the relationship between some parameters: weight, energy intake, and meal frequency. A P-value of less than 0.05 was considered as statistically signiÞ cant.

Food intake assessment
The significant decrease -335 Kcal/d (-18.38%: P < 0.0001) in TEI during T2 (1823 ± 262 vs.1488 ± 118 Kcal/d), constituted the second Þ nding of this study as shown in Table 2. The meal frequency also decreased during Ramadan when compared to T1 (2.2 ± 0.3 vs. 4.3 ± 0.4). The "Ift ar" represented 76.49% of the TEI, while the "Sahur" counted only for 14.13% of the TEI. The dinner, which is taken a few hours aft er "Ift ar" and usually aft er "Taraouih prayers" (religious prayer off ered each night of Ramadan), represented just 2.08% of the TEI. As for the last meal "Sahur" it represented 14.13% of the total energy intake. Regarding nonfasting days, T1/T3, the majority of the daily calories were supplied by lunch (>35% of TEI) and dinner (~ 30% of TEI).

Drug intake
We did not observe any frequent hypoglycaemic episodes in our diabetic patients treated with metformin and/or glimepiride, except for three cases: two patients took their medication without eating "Sahur" and one expended an important amount of physical energy.

Discussion
Obesity and weight gain are considered to be among the most substantial risk factors for developing T2DM. [22] In diabetic obese individuals, weight gain deserves high priority because about 80% of people with T2DM are overweight or have abdominal obesity. Weight loss during Ramadan constitutes the main beneÞ cial eff ect of fasting in our diabetics, and was correlated with the decrease in energy intake (r 2 =0.180, P < 0.01). However, unfortunately a regain of 2.45 kg was observed in T3 and was linked both to an increase in calorie intake (r 2 =0.177, P < 0.01) and to diet mismanagement. It has been shown that a loss of about 4.5 to 9 kg is helpful and should be maintained on a long-term basis to avoid rapid regaining of weight pre fasting level. [23] According to Azizi and Siahkolah, [14] overweight subjects lose more weight, during Ramadan, than those deemed normal or underweight. The other anthropometric parameters (WC, WHR) showed no signiÞ cant diff erence throughout the three periods.
Concerning the Ramadan diet, literature reveals that meal frequency decreases in healthy people as well as in diabetics. In our patients, we noticed a decrease in the number of meals that signiÞ cantly contributed to reduce the amount of calories (r 2 =0.412, P < 0.001). "Ift ar" is the main meal during this period and increases substantially the TEI (r 2 =0.802), as illustrated in Figure  1, due to the change in eating habits among nearly all patients who preferred taking their meal one at a time, while others preferred having soup or a glass of milk and the rest of the meal would be eaten aft er practicing "Taraouih" prayers. These eating habits depended on place and family customs. The total calories brought  *Data are given as mean ± Standard deviation. † First meal (at sunset), ‡ Last meal (before sunrise). SigniÞ cant difference between fasting " # " and non fasting days " § " (P < 0.001). TEI, total energy intake.
by "Ift ar", nibbling, and dinner represented about 80% of the TEI and were consumed within a very limited amount of time in the evening (~ 4-5 hours interval). "Sahur" brought only 14.13% of energy calories, because several patients (31%) were not used to waking up early (dawn) and skipped the meal. However, this later is very important, because it enables diabetic fasters to avoid hypoglycaemic discomforts throughout the fasting day, particularly for patients observed their medical prescription before undertaking the fasting. The Ramadan fasting diet appears to be a good opportunity to reduce calorie intake (-335 kcal/d) caused by a reduction in meal frequency. During nonfasting days (T1 and T3), some patients try to skip some meals in order to lose a few kilograms, like breakfast, and as a result calories of lunch increased to 37.20 % of TEI for T1and to 35.05 % of TEI for T3.
In patients with diabetes, no clear-cut formula exists for the three nutrient intakes (carbohydrate, fat, and protein), and the key is that the calorie intake will be relative to the calorie output. The contribution of carbohydrates and monounsaturated fats should be individualized and based on nutritional assessment, metabolic proÞ le, and treatment goals. [24] Currently, the average amount of carbohydrates recommended for patients with diabetes is 55-60% of the TEI, and litt le evidence is available to support the belief that sugar should be avoided or that starch should be favoured. [25] Therefore, in agreement with the National Academy of Sciences -Food and Nutrition Board, [26] the recommended range of carbohydrate intake is 45-65% of TEI. Ramadan fasting induces a signiÞ cant decrease (P < 0.001) in carbohydrates, because obese women who want to improve their serum glucose and reduce calories, refrain from eating sweet or starchy foods, following their physician's advice. Consequently, as we have observed, they consumed more fatt y foods, thus increasing their consumption during Ramadan (35.84% of TEI), which exceeds dietary recommendations and conventional therapy values for treating obesity (25-30%). [23] The current dietary recommendations recognize that the total amount of carbohydrates is more important than its type, and diets with very low amounts of this nutrient tend to be high in fat and are therefore associated with weight gain and heart disease. [27] More saturated fatt y acids (15.50% of TEI) and dietary cholesterol (397 ± 124 mg/d) were brought during Ramadan. This was due to the foods rich in these nutrients, such as eggs, meat, chicken, fried food, various salads with mayonnaise, dairy fats, and shortening, which were highly consumed during Ramadan, whereas the dietary guidance for diabetics recommends that < 7% of SFA is derived from saturated fats. [23] Regarding the MUFA, we Þ nd considerable solid scientiÞ c support in literature regarding their role in the treatment and prevention of T2DM, [28,29] but quantities that are consumed throughout the three periods are still insuffi cient. In the region, that we studied (Sidi Bel-Abbes and Saida), food rich in MUFA were poorly consumed, except for the town of Oran located on Algerian coast and where Þ sh and seafood are more readily available.
Owing to the excessive use of vegetable oils, such as sunflower oil or margarine, the amounts of PUFA represented by LA of 15 ± 2.3g/d -which accounted for about 80% of the total polyunsaturated fatt y acids, and TFA of 6.3 ± 2.0 g/d, were higher during Ramadan than other periods [ Table 1]. Concerning the omega-3 fatt y acids that are considered as beneÞ cial for diabetics, [30] their consumption was not suffi cient, especially for the EPA. The same Þ nding was observed for the ALA throughout the three periods [ Table 1]. This was probably caused by the fact that the major sources of this nutrient, which are ß axseed, soy bean, canola, wheat germ, or walnuts oils, are not generally consumed in Algeria.
The high reported values of LA/ALA ratio (> 21) showed a signiÞ cant consumption of LA against ALA. Similar to the general population, intake of proteins, in type 2 diabetics, should be 10-20% of the TEI. Ramadan diet brought more food rich in proteins when compared with other periods. This is the case, because various dishes based on meat, dairy product, and fruits were consumed in greater numbers during this month.
Interview results suggested that physical activity was considered as moderate and was restricted to housework and walking, which is the most popular form of activity for the majority of patients, and we did not observe any signiÞ cant change in the investigated periods. Still, during Ramadan daytime, some women feared hypoglycaemia and deliberately decreased their physical activity by sleeping or watching television. These Þ ndings are in accordance with those obtained by the EPIDIAR study [31] carried out in 13 Muslim countries over 11000 patients with T2DM, whose daily physical activity was considered as light to moderate for 94% of the studied population and remained unchanged in approximately half of them.
Concerning the drug intake during Ramadan, no signs or symptoms of hypoglycaemia were observed among the diabetic women participating in the study, except for three cases; two patients took their medication (Glimepiride 4mg) and ate nothing at dawn, "Sahur", and the third undertook strenuous physical eff ort during the daytime. We noticed that, in the last cited study and in one-fourth of patients under oral treatment, the change in OADs doses by diabetics induced severe hypoglycaemic symptoms. [31] Some authors suggest that the modification of lifestyle and food intakes, which occur during Ramadan, should take into account an appropriate OAD. [32] The GLIRA (Glimepiride in Ramadan) study [ 33] and recent Þ ndings of Anwar et al, [34] highlighted the beneÞ cial eff ect of Glimepiride with its longer period of action among patients with T2DM during Ramadan. According to Shaik et al [35] and the ADA work group report, [36] diabetics with obesity who take Metformin, are at minimal risk of hypoglycaemia. Otherwise, we did not observe any diff erence in the frequency of hypoglycaemia between the group taking Metformin and the group being administered bitherapy (i.e. Metformin plus Glimepiride). Finally, we should say that for our diabetics, Ramadan fasting constituted neither inconvenience nor discomfort and on the contrary they felt healthy when they worshipped and took precautions for their diabetes simulataniously.

Conclusion
For obese people and particularly for diabetics, Ramadan fasting represents an excellent opportunity to initiate healthy lifestyle changes and to lose weight. It gives a real motivation for self management, which is highly needed during this period of the year. Moreover, the change in eating patt erns, which occurs during this month, breaks previous habits. Nevertheless, when managing diabetes during this period, other points should be considered for diabetics whose physicians deem capable of fasting -quality of diet, physical activity, and choice of OADbecause it is oft en said that the beneÞ cial eff ects of fasting during Ramadan will occur only in the patients who maintain a diet that is appropriate to them. Ramadan fasting induces weight loss, which was correlated with a decrease in the number of meals and calorie intake. Unfortunately, this weight loss was not maintained one month aft er the end of the fasting period, due to the mismanagement of eating habits and lifestyle. The TEI decreases during Ramadan, whereas the dietary fat consumption increases because of an augmentation of fatt y food that does not occur during other periods (T1 and T3), as well as saturated food with a high amount of TFA, LA, and cholesterol due to the excessive use of vegetable oil and the high consumption of fried food. As reported by the ADA work group report, [36] hypoglycaemia is less frequent in patients with T2DM than type 1 diabetes and with less severe consequences.
These Þ ndings show that there is no contraindication for T2DM to fast during Ramadan. Only three subjects developed hypoglycaemic episodes. If appropriate instructions concerning diet and medication regimen are followed, this will not happen. For diabetics who wish to fast safely, diet modiÞ cation remains a frontline strategy for controlling diabetes during this period. The medication regimen needs to be modiÞ ed in timing and possibly in dosage, and should be adapted to the needs of individual patients.