Ashraf El-Mitwalli et al.

51
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

I ntroduction: 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 profil es
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 (60.712.7 y and 59.712.1 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)


INTRODUCTION

Stroke is one of the major causes of death and
disability in most developed countries
1-3
.
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 sunset
9
. 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 habits
10
. 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 adults
12
. We sought to prospectively study
the effect of fasting and its duration on the stroke
frequency and type.

Correspondence to Ashraf El-Mitwalli, e-mail: Metwally99@yahoo.com. Contact number: 0020102414864
Egypt J. Neurol. Psychiat. Neurosurg. Vol. 46 (1) - Jan
2009
52
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
60.712.7 y for fasting group and 59.712.1 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 {2=0.24 p= 0.94}
(Fig. 1).
Ashraf El-Mitwalli et al.
53
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) 60.712.7 59.712.1 NS
Baseline NIHSS 10.026.4 10.16.8 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
MeanSD
Before Ramadan
MeanSD
Significance
RBCs mil/cmm 4.80.73 4.50.73 NS
Hemoglobin gm/dl 11.92.1 12.51.5 NS
Hematocrit % 39.85.3 36.46.4 NS
WBCs /cmm 8.13.6 8.93.6 NS
Platelets 1000/cmm 214.494 176.877.6 NS
aPTT sec 32.63.2 34.36.1 NS
PT sec 14.61.1 14.61.6 NS
INR 1.20.1 1.20.2 NS
ALT u/l 32.812.2 28.821.4 NS
Albumin g/dl 3.90.6 3.80.4 NS
RBS mg/dl 144.179.7 166.990.7 NS
Creatinine mg/dl 0.90.4 1.31.3 NS
Cholesterol mg/dl 194.747.3 192.145.4 NS
HDL mg/dl 40.75.9 415.9 NS
LDL mg/dl 126.839.9 126.339.5 NS
Triglycerides mg/dl 130.832.2 12932 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)
Egypt J. Neurol. Psychiat. Neurosurg. Vol. 46 (1) - Jan
2009
54
28
24
21
25
13
10
6
5
5
6
3
3
0
5
10
15
20
25
30
35
40
12
hours
14
hours
15
hours
16
hours
18
hours
20
hours
Ischemic Hemorrahgic

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 year
13,14
. Another study found no
negative or positive effects of Ramadan fasting on
stroke frequency
11
. 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 months
15
.
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 parameters
16
and blood glucose was not
influenced by fasting
17
. Ramadan fasting has not
adversely affected leucocytic count or coagulation
parameters
18
.
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
Ashraf El-Mitwalli et al.
55
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
unchanged
17
, while another study reported an
increase in plasma triglycerides accompanied by a
decrease in total cholesterol
19
, 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 men
21
.
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.

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