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July2014 Vol.51 Issue:      3 (Supp.) Table of Contents
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Is There Any Consequence of Ramadan Fasting on Acute Cerebral Stroke?

Hassan Salama, Tamer Belal

Department of Neurology, Mansoura University, Egypt



ABSTRACT

Background: According to Islam’s pillars, all healthy post-puberty Muslims must fast Ramadan from dawn to nightfall. The fasting hours differ according to the season and geographical site. Throughout fasting, Muslims quit from taking anything orally even medications. It was presumed that fasting alter body composition and fluid balance that may herald risky patients to stroke. Objective: To report whether fasting during Ramadan with changing in daily habits and activities has any effect on stroke frequency, type and outcome. Methods: This prospective hospital based study over three consecutive years was completed in Egypt delta province for cerebral stroke patients who were admitted to neurology department, Mansoura University hospitals, one month before (BR), during (DR), and after (AR) Ramadan over three Hijri years. The enrolled patients were classified into two groups: fasting and non-fasting BR, DR or AR. Each patient was subjected to history taking, neurological examination and NIHSS. Laboratory investigations including radiology were done for all patients on admission. Results: A total of 1062 patients were enrolled over three consecutive Hijri years. DR, Most of ischemic stroke onset was around noon (9 am to 4 pm). All patient’s characteristics and laboratory investigations demonstrated no statistical significant differences apart from high mortality rate, hematocrit, and hyperlipidemia among fasting persons. Conclusion: The results indicated that the pattern of fasting DR did not increase the stroke frequency. There was time switch of stroke presentation because of the circadian rhythm changes associated with Ramadan fasting. [Egypt J Neurol Psychiat Neurosurg.  2014; 51(3): 333-336]

Key words: Stroke, Ramadan

Correspondence to Hassan H. Salama, Department of Neurology, Mansoura University; Egypt. Tel.: +201005067491   Email: profhassansalama@gmail.com






INTRODUCTION

 

Stroke prevalence is approximately 5/1000 population but in 65 to 74 year old is 50/1000 in men and 25/1000 in women. Stroke incidence is 2.3/1000.1 Seasonal variation studies revealed higher mortality and hospital admission rates during winter than summer month as well diurnal variation researches suggested high frequent ischemic stroke subtype in the first two hours after waking in the morning.2  

According to Islam’s pillars, all healthy post-puberty Muslims must fast a lunar month named Ramadan (ninth Hijri month) from dawn to nightfall according to the Muslim’s holly book (QUR’AN) instructions but if any person is sick or on a journey or women during menses, pregnancy or lactation, the same number should be made up from other days.3 

The fasting hours differ according to the season and geographical site. Throughout fasting, Muslims quit from taking anything orally even medications. Muslims eat two meals overnight. As well, timetables for sleep, meals, medications and habits rescheduled which may have consequences on high-risk stroke individuals. Anyhow, Muslims are supposed to be at high spiritual level, away from any stress and more calm.3

The Hijri calendar advances 11 days a year on the Gregorian calendar. Accordingly, Ramadan will be in different seasons according to a 33-year cycle. The average fast period during Ramadan is 12 hours; but Muslims living in Polar Regions during summertime adapt to fast according to Mecca’s timetable.3

Despite about 1.3 billion Muslims worldwide, there is a lack of statistics on cerebral stroke incidence during Ramadan. The purpose of this current hospital-based study to report whether fasting during Ramadan with changing in daily habits and activities have any effect on stroke frequency, type and outcome.

 

PATIENTS AND METHODS

 

The present hospital based study over three consecutive years was done in Egypt delta province. The neurology department provides all care types in the region via inpatient and outpatient departments (OPD), making it a proper place for this hospital-based study.

All patients’ records were written by neurologist using the neurology sheets and forms of National Institute of Health and Stroke Scale Score (NIHSS) at the moment of admission and just before discharge. All common risk factors such as age, gender, and occupation, beside suspected uncommon ones were documented.

This prospective study enrolled all adult patients with cerebral stroke who were admitted to neurology department, Mansoura university hospitals, one month before, during, and one month after Ramadan over three Hijri years {1432 (2011), 1433 (2012) and 1434 (2013)}.

The enrolled patients were classified into two groups: fasting and non-fasting (Muslims or non-Muslims) before (BR), during (DR) or after (AR) Ramadan. Each patient was subjected to a systematic history taking, the risk factors outline, related medical examinations, full neurological examinations and NIHSS score. Laboratory investigations were done for all patients on admission; the type of stroke was determined–based on clinical suspicious and brain computerized tomography (CT) scan.

The stroke onset time in the present study was documented as possible but generally, the accumulative fasting effect on stroke frequency and type through the whole Ramadan month was considered. We excluded all patients without clear stroke history or patients with past history of stroke with recent confusion state with no clear cerebral structural lesion.

 

Statistical Analysis

The demographic, clinical and laboratory data were collected using a ‘data collection form’ and entered into a computerized database using Statistical Package for Social Sciences (SPSS) version 15.0 (Chicago, IL, USA) before analysis. Continuous variables were compared using analysis of variance for repeated measures. Student's t-test for mean values of two continuous variables and Mann-Whitney test for non-parametric distribution. P-value less than (0.05) was considered statistically significant. All data were expressed as mean ± standard deviation (SD) or patient’s number (n) and percentage (%) as appropriate.

 

RESULTS

 

A total of 1062 patients were enrolled over three consecutive Hijri years {1432 (2011), 1433 (2012) and 1434 (2013)} where three months each year had been studied, a month before, during and after Ramadan all of them were in summer and autumn.

Mansoura emergency hospital is working three days a week for causality. Therefore, according to Lunar months during the whole three Hijri years, there were 39 (367 patients), 36 (379 patients), 39 (316 patients) emergency days and patients before, during and after Ramadan respectively. 

During Ramadan, Most of ischemic stroke onset was around noon between 9am to 4pm, where most of patients went to sleep after dawn praying and most of them take a nap at night. The months around Ramadan, there is no clear stroke onset but most of them claim the onset most probably started after midnight and before dawn. As regards hemorrhagic stroke, there was considerable observation of occurrence at night for fasting group.

The mean age of stroke was 63.45±10.36, 64.22±11.86 and 63.34±10.93y for before, during and after fasting groups respectively. There was no statistical significant difference in the sex ratio the mean NIHSS score between the three groups (P>0.05). 

As mentioned in Tables (1) and (2), all patient’s characteristics and laboratory investigations demonstrated no significant differences apart from mortality rate, hematocrit, hyperlipidemia and number of fasting persons.


 

Table 1. Demographic data and patient’s characteristics.

 

 

Before Ramadan

During Ramadan

After Ramadan

P-value

Patients N°.

379

367

316

<0.05

Average  N° /day

9.72

10.19

8.1

<0.05

Age mean ± SD

63.45±10.36

64.22±11.86

63.34±10.93

>0.05

Gender   M % (N°)

               F % (N°)

59.9 (227)

40.1 (152)

59.9 (220)

40.1 (147)

61.7 (195)

38.3(121)

>0.05

>0.05

Fasting % (N°)

Non-fasting  % (N°)

3.9 (15)

96.1 (364)

81.7 (300)

18.3 (67)

13.6 (43)

86.4 (273)

<0.05

<0.05

Stroke type

Hemorrhage % (N°)

Ischemia % (N°)

 

17.9 (68)

82.1 (311)

 

16.9 (62)

83.1 (305)

 

18 (57)

82 (259)

 

NIHSS on admission

12.3±5.2

13.24±5.1

11.92±5.6

<0.05

Risk factors %

   Hypertension

   DM

   Heart diseases

   TIA

   Multiple factors

 

53.8

45.8

41.9

25.3

70.4

 

54.2

44.1

40.1

26.7

70.6

 

52.2

43

39.2

24.1

69.3

 

>0.05

>0.05

>0.05

>0.05

>0.05

Table 2. Clinical and laboratory results.

 


 

Before Ramadan

(N°=379)

During Ramadan

(N°=367)

After Ramadan

(N°=316)

P-value

Number of casualty days

39

36

39

>0.05

Lateralization (%)

Rt.

Lt.

No

 

52.24

42.22

5.54

 

53.13

40.06

6.81

 

49.68

43.04

7.28

 

>0.05

>0.05

>0.05

Brain CT findings (%)

Apparently normal

Inf. or Hemorrhage

 

56.2

43.8

 

57.2

42.8

 

53.8

46.2

 

>0.05

>0.05

Laboratory findings

Mean ± SD

Hct (%)

Hb (gm/dl)

INR

High risk patients’ %

Hyperlipidemia

Impaired LFT

Impaired RFT

Multiple

 

 

34.8±4.8

11.7±1.9

1.1±0.2

 

11.8

21.1

3.4

5.5

 

 

40.1±5.2

12.1±2.3

1.2±0.1

 

13.6

26.4

3.3

5.2

 

 

35.9±4.6

11.3±1.6

1.1±0.1

 

11.1

20.9

3.5

4.7

 

 

<0.05*

>0.05

>0.05

 

<0.05*

<0.05*

>0.05

>0.05

Mortality N° (total no.)

Ischemic stroke

Hemorrhagic stroke

 

49 (total N°=311)

17 (total no=68)

 

76 (total N°=305)

26 (total no=62)

 

41(total N°=259)

15 (total no=57)

 

<0.05*

<0.05*

*Significant

 


DISCUSSION

 

The current study clarified a significant difference in the stroke frequency before and during Ramadan, when compared to the month after Ramadan that may related to diet attitude and fluid intake after Ramadan as well as positive emotional factors.

There was no considerable statistically difference found between the study years for the frequency of stroke and other clinical characteristics of enrolled patients, for instance age at onset, gender, cardiovascular risk factors (diabetes mellitus, hypertension, coronary heart disease,  smoking, and hypercholesterolemia), or double stroke where a tendency for the stroke cases to decease in month after Ramadan.4,5 

The present study went with Maislos et al study and showed increase level of plasma high-density lipoprotein (HDL) during Ramadan in comparison with months before and after (p<0.05).6 Sadatania et al. stated that fasting during Ramadan may increase antioxidant activity. Unfortunately, hematocrit and total lipid profile increased that would be explained stroke aggressiveness either hemorrhagic or ischemic and high mortality rate during the fasting month (p<0.05).7

Beside lipid profile and hematocrit value, Ramadan alters body composition, blood components and physical activity, as well as dehydration, loss of substances consumption with negative inotropy and alters circadian rhythms could explain high mortality rate during fasting and aggressive stroke presentation that commonly occurred at afternoon.4,6

There is switch in the timing of stroke presentation because of the circadian rhythm changes associated with Ramadan fasting, ischemic became more common at afternoon and considerable hemorrhagic ones at night after breaking the fast of the day in comparison with month before and after where both had the same usual pattern of ischemic at early morning or late night and hemorrhagic stroke at noon.8-10

No stroke frequency differences among non-Muslim during Ramadan or nonfasting Muslims and general stroke incidence during the whole year.11

The current evidence suggests a potential role of fasting in mortality but not in outcome of stroke. There is a great need to develop clinical and biomarkers guideline specific for fasting decision.11-13 

The major limitation of present study is no statistics on those who refused hospitalization, died before arrival, or died at home from acute stroke as well as stroke incidence all over the country during Ramadan.

The type and severity of stroke as well as the diurnal frequency will depend more on circadian but the eating habit still has a role. In Egypt, non-Muslim sharing Muslims in many habits during Ramadan and they respect this month, so it is very difficult to find non-Muslims take any food in streets or work places. Generally, this point needs more detailed research especially in other countries. 

Briefly, the present study included the stroke frequency over 3-year period. The present results indicated that the pattern of fasting during Ramadan does not increase the frequency of stroke occurrence. There is no statistically significant difference between stroke rates in the Ramadan fasting month and other non-fasting months except the month after Ramadan. These finding may be explained by changing dietary habits and moving towards erratic eating behavior after the obligatory restriction during Ramadan.14

 

[Disclosure: Authors report no conflict of Interest]

 

REFERENCES

 

1.      Go AS, Mozaffarian D, Roger VL, Benjamin EJ, Berry JD, Borden WB. Executive summary: heart disease and stroke statistics-2014 update: a report from the American Heart Association. Circulation. 2014; 129 (3):399-410.

2.      World Health Organization: Statistical Annex. The World Health Report 2004. Geneva, Switzerland: WHO; 2004.

3.      Sakr AH. Fasting in Islam. J Am Diet Assoc. 1975; 67 (1): 17-21.

4.      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.

5.      Akhan G, Kutluhan S, Koyuncuoglu HR. Is there any change of stroke incidence during Ramadan? Acta Neurol Scand. 2000; 101(4):259-61.

6.      Maislos M1, Abou-Rabiah Y, Zuili I, Iordash S, Shany S. Gorging and plasma HDL-cholesterol-the Ramadan model. Eur J Clin Nutr. 1998; 52(2):127-30.

7.      Saadatnia M, Zare M, Fatehi F, Ahmadi A. The effect of fasting on cerebral venous and dural sinus thrombosis. Neurol Res. 2009; 31(8):794-8.

8.      Akhan G, Kutluhan S, Koyuncuoglu HR. Is there any change of stroke incidence during Ramadan? Acta Neurol Scand. 2000; 101(4):259-61.

9.      El-Mitwalli A, Zaher A, Abd El-Salam M, Elmenshawi E. The Effect of Ramadan Fasting on Cerebral Stroke: A Prospective Hospital-Based Study. Egypt J Neurol Psychiat Neurosurg. 2009, 46(1): 51-6

10.    Kutluhan S, Sandik i Y, Aytekin S. The relationship of Ramadan with cerebrovascular diseases. J Vakõf Gureba Hospitals. 1996; 21: 269-74.

11.    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.

12.    Ince B, Turgut N, Celik Y. Effect of Ramadan on occurrence and prognosis of stroke. J Turk Assoc Neurol. 1997; 3: 68.

13.    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.

14.    Sakr AH. Dietary regulations and food habits of Muslims. J Am Diet Assoc. 1971; 58(2):123-6.


 

الملخص العربى

 

هل هناك أي توابع لصوم رمضان على السكتة الدماغية الحادة؟

 

تعتبر فريضة الصوم واجبه على كل مسلم بالغ عاقل قادر على صوم هذا الركن من أركان الاسلامى وحيث أن المسلمين يصامون طبقا للتقويم الهجري القمري فأن شهر رمضان يأتي فى فصول مختلفة وتكون فترة الصوم مختلفة من عام إلى آخر. كان هدف البحث توضيح العلاقة بين الصوم والعادات المصاحبة له مثل نظام النوم والطعام على نوع ومعدل وخطورة السكتة الدماغية.  يعتبر هذا بحث معتمد على المعلومات الواردة من قسم طب المخ والأعصاب بمستشفى المنصورة الجامعى على مدار ثلاثة سنوات متتالية وقد تم تقسيم المرضى إلى ثلاثة مجموعات مجموعه شهر شعبان ومجموعه شهر رمضان ومجموعه شهر شوال وتم تقسيم مجموعه رمضان إلى صائمين وغير صائمين وكل مريض تم فحصه من الناحية الاكلينيكيه والاشعه المقطعية والتحاليل المعملية ألازمه وتقيم تبعا إلى المعهد الوطني للاضطرابات العصبية والسكتة الدماغية وكانت النتائج بين المرضى الألف واثنين وستون حيث كان حدوث الجلطات فى مجموعه شهر رمضان الصائمة بين الساعة التاسعة صباحا والرابعة عصرا وكانت الجلطات عنيفة ومعدل الوفيات عالي بهذه المجموعة وأيضا نسبه الدهون بالدم ولكن ما دون ذلك لم يكن له مردود إحصائي تميزي. ويمكن استنتاج أن معدل الوفيات لم يزيد فى شهر رمضان عن باقى الشهور ولكن اختلف موعد حدوث السكتة الدماغية وحدتها.



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