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January2009 Vol.46 Issue:      1 Table of Contents
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The Effect of Ramadan Fasting on Cerebral Stroke: A Prospective Hospital-Based Study

Ashraf El-Mitwalli, Ashraf Ahmed Zaher, Mohamed Abd El-Salam Mohamed, Ebrahim Elmenshawi


Department of Neurology, Mansoura University




ABSTRACT

Introduction: Over one billion Muslims fast worldwide during the month of Ramadan. Fasting during Ramadan is a radical change in lifestyle for the period of a lunar month. The objective of this study was to investigate whether Ramadan fasting has any effect on stroke frequency and type. Patients and Methods: We prospectively studied consecutive stroke Muslim patients who were hospitalized with stroke one month before, and during Ramadan over two successive years 2007 and 2008. The age of presentation, gender, risk factor profiles including smoking status, hypertension, hypercholesterolemia, diabetes mellitus, and pre-existing cardiovascular disease were analyzed. The NIHSS score was used for clinical assessment of all patients at admission. The exact time of stroke onset in fasting patients, the time of the last meal before starting fasting from which we calculated the duration of fasting before the onset of stroke. Results: A total of 517 patients were studied over a period of 4 months; a month before Ramadan and Ramadan month each year in 2 successive years (before Ramadan 262 patients and 245 patients During Ramadan). The age distribution of patients was not significantly different between the 2 groups (60.7±12.7 y and 59.7±12.1 y) for the fasting and non fasting group respectively. There was no statistical significant difference in the sex ratio, risk factors, mean baseline NIHSS score and ratios of hemorrhagic and ischemic stroke between the two groups (P>0.05). There was no statistically significant difference in the laboratory findings, Also, no correlation was found between the duration of fasting and both the frequency and the type of stroke. Conclusion: Ramadan fasting has no effects on stroke frequency, type, and severity. The duration of fasting has no effect on either frequency or type of stroke.  (Egypt J. Neurol. Psychiat. Neurosurg., 2009, 46(1): 51-56)


Correspondence to Ashraf El-Mitwalli, e-mail: Metwally99@yahoo.com. Contact number: 0020102414864






INTRODUCTION

 

Stroke is one of the major causes of death and disability in most developed countries1-3. Cardiovascular disease and stroke are approaching epidemic proportions worldwide, and are associated with substantial public and personal burdens.1-8

 

During the month of Ramadan, Muslims neither eat nor drink anything during the month, between dawn and sunset9. Fasting may last 11-20 hours depending on geographical location and season. Following hunger during the above-mentioned period, at sunset people usually eat a large meal, and before dawn, people have another meal. This change of meal schedule is accompanied with changes in sleeping habits10. So, fasting during Ramadan is essentially a radical change in lifestyle for the period of one lunar month that may affect cardiac and stroke patients.4,5,11

 

Ramadan fasting is a great opportunity for scientific research due to its peculiar nature. Despite the fact that it concerns the Muslim community of more than 1 billion people, the effects of fasting on humans have not been adequately investigated. To the best of our knowledge, there is no prospective study on the effect of Ramadan fasting on cerebral stroke which is one of the most common causes of death in adults12. We sought to prospectively study the effect of fasting and its duration on the stroke frequency and type.

 

PATIENTS AND METHODS

 

We prospectively studied consecutive adult stroke patients admitted to the stroke unit, department of neurology, Mansoura university hospitals, Mansoura, Egypt a month before and during the month of Ramadan over the years 2007 and 2008.

The studied patients were classified into 2 groups fasting (during Ramadan month for 2 years) and non -fasting (a month previous to Ramadan each year). Each patient was subjected to a thorough history taking; including; the risk factors profile, clinical, neurological examinations and a baseline NIHSS score. Baseline laboratory investigations were done on admission, the type of stroke - ischaemic or haemorrhagic was ascertained - based on clinical and computerized tomography (CT) brain scan results.

Stroke onset time was defined as the earliest time patient or witness noticed definite neurological symptoms or signs. The time was obtained from the history given by the patient, relative or bystander. We tried to ascertain the time of stroke onset to the nearest possible hour. Patients were excluded from studying the effect of fasting duration whenever the time of stroke onset could not be determined as patients were unconscious or aphasic or witness account could not be obtained. In fasting patients the time of the last meal was registered and from which the duration of fasting preceded the onset of stroke was calculated.

The data were coded and entered into a computer using Statistical Package for Social Sciences (SPSS) version 15.0 (Chicago, IL, USA). Data are expressed as mean ± standard deviation (SD) unless otherwise stated. Student's t-test was used to ascertain the significance of differences between mean values of two continuous variables and Mann-Whitney test was used for non-parametric distribution. Chi-square analysis was performed to test for differences in proportions of categorical variables between two or more groups. The level of p<0.05 was considered the cut-off value of significance.

 

RESULTS

 

A total of 517 patients were studied over a period of 4 months a month before Ramadan and Ramadan month each year in 2 successive years 2007and 2008. During Ramadan, 245 patients were admitted to our department (4.08 patient per day) and 262 patients were admitted a month before Ramadan in the 2 years with a rate of (4.36 patients per day).

The clinical characteristics of all patients are shown in (Table 1). The age distribution of patients was not significantly different between the 2 groups (P>0.05). Mean age at the onset of stroke was 60.7±12.7 y for fasting group and 59.7±12.1 y for the non fasting group. There was no statistical significant difference in the sex ratio between the two groups (P>0.05). Also, there was no significant difference in the mean baseline NIHSS score between the two groups.

The frequency of previous stroke, hypertension, diabetes mellitus, heart disease and history of stroke was not significant between the period before and during Ramadan (P>0.05). Ischemic stroke is the most frequently observed clinical pattern of disease (P<0.05). The ratios of hemorrhagic and ischemic stroke were not significantly different in the two groups (P>0.05).

The laboratory findings on admission are shown in (Table 2). There was no statistically significant difference in the laboratory findings including the complete blood count, lipid profile, baseline blood glucose level, creatinine, albumen, ALT, prothrombin time and activated partial thromboplastin time between the two groups.

The duration of fasting was calculated by deducing the time of the last meal from that of the stroke onset in all fasting patients, the least was 12 hours for any fasting patient, sometimes patients did not eat their before dawn meal and made the fasting duration more longer; there was no significant relation between the duration of fasting and both the frequency and the type of stroke {χ2=0.24 p= 0.94} (Fig. 1).

Table 1. Clinical characteristics of the patients before and during the month of Ramadan.

 

 

During Ramadan fasting

Before Ramadan

Significance

No.

245(4.08/day)

262(4.36/day)

NS

Gender

           Male n (%)

           Female n (%)

 

115 (46.9)

130 (53.1)

 

143 (54.6)

119 (45.4)

 

NS

NS

Age (Mean± SD)

60.7±12.7

59.7±12.1

NS

Baseline NIHSS

10.02±6.4

10.1±6.8

NS

Stroke type

     Ischemic (%)

     Hemorrhagic (%)

 

80.8

19.2

 

84.1

15.9

 

NS

NS

Previous stroke (%)

17.6

22.1

NS

Diabetes Mellitus (%)

21.6

27.1

NS

Hypertension (%)

54.3

49.2

NS

Cardiac disease (%)

24.1

30.2

NS

National Institute of Health and Stroke Scale Score (NIHSS)

 

Table 2. Laboratory data before and during the month of Ramadan.

 

 

Unit

During Ramadan Fasting

Mean±SD

Before Ramadan

Mean±SD

Significance

RBCs

mil/cmm

4.8±0.73

4.5±0.73

NS

Hemoglobin

gm/dl

11.9±2.1

12.5±1.5

NS

Hematocrit

%

39.8±5.3

36.4±6.4

NS

WBCs

/cmm

8.1±3.6

8.9±3.6

NS

Platelets

1000/cmm

214.4±94

176.8±77.6

NS

aPTT

sec

32.6±3.2

34.3±6.1

NS

PT

sec

14.6±1.1

14.6±1.6

NS

INR

 

1.2±0.1

1.2±0.2

NS

ALT

u/l

32.8±12.2

28.8±21.4

NS

Albumin

g/dl

3.9±0.6

3.8±0.4

NS

RBS

mg/dl

144.1±79.7

166.9±90.7

NS

Creatinine

mg/dl

0.9±0.4

1.3±1.3

NS

Cholesterol

mg/dl

194.7±47.3

192.1±45.4

NS

HDL

mg/dl

40.7±5.9

41±5.9

NS

LDL

mg/dl

126.8±39.9

126.3±39.5

NS

Triglycerides

mg/dl

130.8±32.2

129±32

NS

Red blood corpuscles (RBCs), White blood corpuscles (WBCs), activated partial prothrombin (aPTT), Prothrombin Time (PT) International Normalized Ratio (INR), Random Blood Sugar (RBS), High Density Lipoprotein (HDL), and Low Density Lipoprotein (LDL)


Fig. (1): frequency and type of stroke in relation to the duration of fasting.

DISCUSSION

 

The current prospective study demonstrated that there was no significant difference in frequency of stroke between patients admitted during the month of Ramadan and non fasting months preceding it, this was in concordance with previous retrospective studies by Ince et al. and Kutluhan et al. who evaluated stroke patients and found no significant differences between Ramadan and other times of the year13,14. Another study found no negative or positive effects of Ramadan fasting on stroke frequency11. A more recent study concluded that, the pattern of fasting during Ramadan does not increase the frequency of hospitalization for stroke incidence. There is no statistically significant difference between stroke rates in the Ramadan fasting month and other non-fasting months15.

Our recent reports have shown that there was no significant difference in baseline laboratory findings between fasting and non fasting groups. They confirmed other reported studies that dietary change did not affect the composition of plasma biochemical parameters16 and blood glucose was not influenced by fasting17. Ramadan fasting has not adversely affected leucocytic count or coagulation parameters18.  

The debate around the dietary changes and the plasma lipoprotein has not been solved yet, our study did not show any significant difference in total cholesterol, triglycerides or high density lipoproteins between fasting and non fasting patients, in line with our results Beltaifa et al. found that, there were non-significant modifications in the plasma lipid fractions. The total cholesterol remained unchanged17, while another study reported an increase in plasma triglycerides accompanied by a decrease in total cholesterol19, but El-Hazmi et al.20, demonstrated that plasma triglycerides and total cholesterol levels decreased after the first week, and subsequently increased towards the end of Ramadan. Maislos et al.16 demonstrated that, plasma high-density lipoprotein cholesterol increased by 23% after four weeks of gorging. The dietary change did not affect the composition of other lipoproteins, other plasma biochemical parameters. Prolonged gorging, well tolerated by all individuals, fasting is a very effective non-pharmacological method to increase plasma HDL-cholesterol, while another study demonstrated that, Ramadan with low fat and low calorie diet leads to plasma lipids reduction in hyperlipidemic men21.

To the best of our knowledge, there were no studies demonstrated the effect of the duration of fasting on either stroke frequency or type, the present study showed that the duration of fasting neither affect frequency or type of stroke. More studies are needed to confirm these results.

In conclusion, Ramadan fasting has no effects on stroke frequency, type and severity. The duration of fasting has no effect on either frequency or type of stroke. 

 

REFERENCES

 

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2.      Truelsen T, Prescott R, Gronbaek M, Schnohr P, Boysen G. Trends in stroke incidence: the Copenhagen City Heart Study 1997; 28:1903-7.

3.      Bonita R, Broad JB, Beaglehole R. Changes in stroke incidence and case-fatality in Auckland, New Zealand, between 1981 and 1991. Lancet 1993; 342:1470-3.

4.      Al Suwaidi J, Bener A, AlBinali H, Numan MT. Does hospitalization for congestive heart failure occur more frequently in Ramadan: a population based study (1991 - 2001)? Int J Cardiol 2004; 96:217-21.

5.      Al Suwaidi J, Bener A, Sulaiman A, AlBinali HA, Salam AM. A population based study of Ramadan fasting and acute coronary syndromes (1991 - 2001). Heart 2004; 90:695-6.

6.      Al Suwaidi J, Bener A, Behair S, AlBinali HA. Mortality caused by acute myocardial infarction in Qatari women. Heart 2004; 90:693-4.

7.      Bener A, Al Suwaidi J, Al Jaber K, Al-Marri S, Elbagi IAE. The epidemiology of hypertension and its associated risk factors in the Qatari population, J Human Hypertens 2004; 18:529-30.

8.      Bener A, Al Suwaidi J, El-Menyar A, Gehani A. The effect of hypertension as a predictor of risk for congestive heart failure patients over a 10-year period in a newly developed country, Blood Pressure 2004; 13:41-6.

9.      Sakr AH. Fasting in Islam. J Am Diet Assoc 1975; 67: 17-21.

10.    Bener A. Galadari S, Gillett M, et al. Fasting during the holy month of Ramadan does not change the composition of breast milk. Nutrition Research 2001; 21:859-64.

11.    Akhan G, Kutluhan S, Koyuncuoglu HR. Is there any change of stroke incidence during Ramadan? Acta Neurol Scand 2000; 101:259-61.

12.    Wolf PA, Cobb Jl, DÕAgostino RB. Epidemiology of stroke. In: ÒStrokeÓ.Barnett HJM, Mohr JP, Stein BM, et al.Eds, New York, Churchill Livingstone 1992; 3-27.

13.    Ince B, Turgut N, .elik Y, et al. Effect of Ramadan on occurrence and prognosis of stroke. J Turkish Association Neurology 1997; 3: 68.

14.    Kutluhan S, Sandiki Y, Aytekin S. The relationship of Ramadan with cerebrovascular diseases. J Vakõf Gureba Hospitals 1996; 21: 269-274.

15.    Bener A, Hamad A, Fares A, Al-Sayed HM, Al-Suwaidi J. Is there any effect of Ramadan fasting on stroke incidence? Singapore Med J 2006; 47(5) : 405).

16.    Maislos M, Abou-Rabiah Y, Zuili I, Iordash S, Shany S. Gorging and plasma HDL-cholesterol--the Ramadan model. Eur J Clin Nutr. 1998 Feb;52(2):127-30.

17.    Beltaifa L, Bouguerra R, Ben Slama C, Jabrane H, El-Khadhi A, Ben Rayana MC, Doghri T. Food intake, and anthropometrical and biological parameters in adult Tunisians during fasting at Ramadan East Mediterr Health J. 2002 Jul-Sep;8(4-5):603-11.

18.    Saleh SA, El-Kemery TA, Farrag KA, Badawy MR, Sarkis NN, Soliman FS, Mangoud H. Ramadan fasting: relation to atherogenic risk among obese Muslims. J Egypt Public Health Assoc. 2004;79(5-6):461-83.

19.    Gumaa KA, Mustafa KY,. Mahmoud NA, Gader AM, The effect of fasting in Ramadan: serum uric acid and lipid concentration. Br J Nutr 1978; 40:573.

20.    El-Hazmi MAF, Al-Faleh FZ, Al-Mofleh I. Effect of Ramadan fasting on the values of hematological and biochemical parameters. Saudi Med J 1987; 8:171-6.

21.    Afrasiabi A, Hassanzadeh S, Sattarivand R, Nouri M, Mahbood S.Effects of low fat and low calorie diet on plasma lipid levels in the fasting month of Ramadan. Saudi Med J. 2003 Feb;24(2):184-8.

 

 

الملخص العربى

خلال شهر رمضان المبارك يصوم حوالى بليون مسلم فى مختلف أنحاء العالم. ويحدث صيام رمضان تغيرا جوهريا فى سلوكيات الحياة على مدى شهر قمرى كامل. تهدف هذه الدراسة الى إظهار تأثير الصيام على السكتة الدماغية من حيث نوعها ومعدل حدوثها. لقد قمنا بدراسة مستقبلية لعدد من مرضى السكتة الدماغية المسلمون الذين ادخلو الى المستشفى فى شهر رمضان والشهر السابق له على مدى العامين 2007-2008 وتم تدوين بيانات المرضى والتى شملت السن، الجنس، عوامل الخطورة شاملة التدخين، ارتفاع ضغط الدم والسكر بالدم، ارتفاع نسبة الدهون وأمراض القلب. وقمنا بفحص جميع المرضى عند دخول المستشفى إكلينيكيا باستخدام اختبار السكتة الدماغية العالمى. وقد تم تحديد توقيت حدوث السكتة الدماغية وعدد ساعات الصيام اعتبارا من آخر وجبة تناولها المريض. وأظهرت النتائج أن عدد المرضى 517 مريض تم دراستهم خلال أربعة اشهر على مدى عامين متتاليين منهم 245 فى شهر رمضان و 262 فى الشهر السابق له. وكانت نتائج الاختبارات الإحصائية انه لا يوجد اى فرق ذو دلالة إحصائية بين المجموعتين من حيث السن، الجنس، عوامل الخطورة، اختبار السكتة الدماغية العالمى، الاختبارات المعملية وأيضا نسبة حدوث الجلطة المخية والنزيف. ولم نجد اى ارتباط بين عدد ساعات الصيام ومعدل حدوث ونوع السكتة الدماغية. نستنتج من ذلك أن صيام شهر رمضان المبارك ليس له اى تأثير على معدل حدوث ونوع السكتة الدماغية وشدتها كما أن عدد ساعات الصيام أيضا ليس له اى تأثير.

 




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