The Impact of Religious Fasting on Human Health PDF

Trepanowski and Bloomer Nutrition Journal 2010, 9:57 http://www.nutritionj.com/content/9/1/57 REVIEW Open Access The impact of religious fasting on human health Jo...

Trepanowski and Bloomer Nutrition Journal 2010, 9:57 http://www.nutritionj.com/content/9/1/57 REVIEW Open Access The impact of religious fasting on human health John F Trepanowski, Richard J Bloomer* Abstract The past two decades have seen a rise in the number of investigations examining the health-related effects of reli- giously motivated fasts. Islamic Ramadan is a 28 - 30 day fast in which food and drink are prohibited during the daylight hours. The majority of health-specific findings related to Ramadan fasting are mixed. The likely causes for these heterogeneous findings are the differences between studies in the following: 1) the amount of daily fasting time; 2) the percentage of subjects who smoke, take oral medications, and/or receive intravenous fluids; and 3) the subjects’ typical food choices and eating habits. Greek Orthodox Christians fast for a total of 180 - 200 days each year, and their main fasting periods are the Nativity Fast (40 days prior to Christmas), Lent (48 days prior to Easter), and the Assumption (15 days in August). The fasting periods are more similar than dissimilar, and they can each be described as a variant of vegetarianism. Some of the more favorable effects of these fasts include the lowering of body mass, total cholesterol, LDL-C, and the LDL-C/HDL-C ratio. The Biblical-based Daniel Fast prohibits the con- sumption of animal products, refined carbohydrates, food additives, preservatives, sweeteners, flavorings, caffeine, and alcohol. It is most commonly partaken for 21 days, although fasts of 10 and 40 days have been observed. Our initial investigation of the Daniel Fast noted favorable effects on several health-related outcomes, including: blood pressure, blood lipids, insulin sensitivity, and biomarkers of oxidative stress. This review summarizes the health- specific effects of these fasts and provides suggestions for future research. Introduction CR regimen: decreases in resting heart rate (HR) and Fasting is defined as a partial or total abstention from all blood pressure (BP); increases in HR variability; and foods, or a select abstention from prohibited foods. As a improvements in left ventricular function, post-exercise potential non-pharmacological intervention for improv- recovery of both HR and BP, and flow-mediated vasodila- ing health and increasing longevity, fasting has been the tion. Regarding glucoregulatory health, CR has been subject of numerous scientific investigations. The three shown to decrease fasting glucose and insulin levels, most commonly studied fasts are caloric restriction increase insulin sensitivity, decrease body fat percentage, (CR), alternate-day fasting (ADF), and dietary restriction and lower the incidence of diabetes [5,6]. (DR). A summary of the main findings is presented ADF consists of alternating 24-hour periods: during below. the “feast period,” fasters may consume food ad libitum; CR is the reduction of kilocalorie (kcal) intake by a cer- during the “fast period,” food consumption is restricted tain percentage (typically 20 - 40%) of ad libitum con- or halted altogether. Water is allowed ad libitum during sumption. CR has been demonstrated to improve health all times. Animal ADF trials have reported extended life- and increase longevity in a diverse group of species, span as well as the retardation or altogether preven- including: dog, fruit fly, nematode, rodent, rotifer, spider, tion of the development of many morbidities, including: non-human primate, and zebrafish. Additionally, CR cardiovascular disease, kidney disease, cancers, and dia- appears to delay the onset of the following diseases: auto- betes [4,7]. ADF has been noted to elicit the following immune diseases, atherosclerosis, cardiomyopathies, can- beneficial changes in cardiovascular health: decreased cer, diabetes, renal diseases, neurodegenerative diseases, HR and BP, increased HR variability, and attenuated and respiratory diseases [2,3]. Regarding cardiovascular post-infarct chronic heart failure [4,8,9]. Regarding glu- health, the following changes have been noted following a coregulatory health, ADF may have gender-specific effects. For example, ADF improved insulin sensitivity in * Correspondence: [email protected] men but had no effect on this variable in women. Cardiorespiratory/Metabolic Laboratory, The University of Memphis, Furthermore, glucose tolerance was unchanged in men Memphis, TN 38152, USA © 2010 Trepanowski and Bloomer; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Trepanowski and Bloomer Nutrition Journal 2010, 9:57 Page 2 of 9 http://www.nutritionj.com/content/9/1/57 partaking in an ADF regimen, but women partaking in with the rest of the year. Also, sugary foods and the same regimen experienced impaired glucose toler- drinks are consumed more frequently during Ramadan ance.. DR is a reduction of one or more components of diet- Upon reaching puberty, all healthy Muslims are ary intake (typically macronutrients) with minimal to no required to partake in the fast. Individuals who are sick, reduction in total kcal intake. Research suggests that traveling, pregnant, breast-feeding, menstruating, or neither carbohydrate restriction nor lipid restriction debilitated are exempt from fasting [18,19]. However, extend life. On the other hand, protein restriction many Muslims who are eligible for exemption choose to increases maximum lifespan by roughly 20% , and fast nonetheless. this extension of life may be solely due to the reduction Due to the fact that the Islamic calendar (Hijra) is a of the amino acid methionine. These findings are in lunar calendar, the first day of Ramadan advances 11 reference to animals, so further work involving human days each year in relation to the Gregorian calendar. test subjects is necessary before firm conclusions can be Consequently, Ramadan falls on different parts of the made. seasonal year over a 33-year cycle. This seasonal shift While religious fasts are partaken primarily for spiri- dramatically impacts the amount of daily fasting time tual purposes, they also have the potential to greatly that occurs in any given location. Moreover, a location’s affect one’s physical health. Accordingly, the health latitudinal distance from the equator also substantially effects of religious fasting have recently been the subject impacts daily fasting time. While the average fast period of scientific inquiry, with most of the research being during Ramadan is 12 hours in length , it can be as performed in the last two decades. The following reli- long as 22 hours in polar regions during summertime gious fasting periods are featured in this review: 1) Isla-. Fortunately, Muslims living in such regions are mic Ramadan; 2) the three principal fasting periods of permitted to adopt the fast period of either Mecca or Greek Orthodox Christianity (Nativity, Lent, and the the nearest temperate location. Assumption); and 3) the Biblical-based Daniel Fast. The The variability in daily fasting time is one of several reason for the inclusion of these specific forms of reli- confounding variables that influence the effect of Rama- gious fasts and the exclusion of others is that, to our dan fasting on health-related biomarkers. Other con- knowledge, these are the only fasts about which scho- founding variables include smoking status, medication, larly research has been performed that explicitly detailed diet, and cultural habits [22-24]. Smoking is forbidden the subjects’ dietary intake and health-related outcomes. during the daylight hours of Ramadan; therefore, a sub- Specifically, this review will examine the effects of these ject population containing a large percentage of smokers fasts on energy and nutrient intake, anthropometry, could conceivably experience changes in health-related hematometry, blood pressure, and other health-related biomarkers simply by virtue of smoking less. This latter biomarkers. This paper concludes with a summarization point similarly applies to a subject population containing of the findings and suggestions for future research. a large percentage of people taking oral medications and/or intravenous fluids, as their usage is also disal- Ramadan lowed during the daylight hours of Ramadan. Each year, millions of Muslims refrain from eating or Regarding diet, energy intake during Ramadan has been drinking from sunrise (Sahur) to sunset (Iftar) during reported to increase in Saudi Muslims and decrease in the holy month of Ramadan, which lasts between 28 Indian Muslims; these discrepant findings are believed and 30 days. Thus, Ramadan fasting is similar to ADF, to be due to the differences in food choices between the because both fasts incorporate feast periods and fast groups. periods. The feast periods and fast periods of Ramadan Few definitive conclusions can currently be made fasting are each 12 hours in length on average , regarding the effects of Ramadan fasting on human which amounts to half of the 24-hour length for both health, because the collective body of research has noted the feast periods and fast periods of ADF. Another mostly heterogeneous findings regarding both dietary important difference between the two forms of fasting is intake and health-related outcomes. The above-listed that fluid intake is forbidden during the fast periods of confounding variables in studies of Ramadan fasting - Ramadan, whereas it is permitted at all times under an particularly the dietary norms of the subjects - are likely ADF protocol. the main causes of these heterogeneous findings. The common dietary practice of Ramadan fasting is to As mentioned above, the majority of findings related consume one large meal after sunset and one lighter to energy and macronutrient intake during Ramadan meal before dawn , but some Muslims consume an fasting are mixed. A summary of available findings per- additional meal before sleeping. Muslims consume taining to daily energy intake as well as the percentage a greater variety of foods during Ramadan compared intake of carbohydrate, protein, and fat is presented in Trepanowski and Bloomer Nutrition Journal 2010, 9:57 Page 3 of 9 http://www.nutritionj.com/content/9/1/57 Table 1 Effects of Ramadan fasting on nutrient intake riboflavin consumption decreased to a level that Outcome Reference Subjects Effect approached significance during Ramadan (p = 0.056). Energy (kcal) Adlouni 32 M ↑ Mixed findings exist regarding the intake of sodium Kassab 44 W 1 and fiber during the fast. Regarding sodium, studies Lamine 9 M & 21 W ↑ reported either decreased consumption or no Rakicioğlu 21 W ↔2 change in consumption. Regarding fiber, studies Al-Hourani 57 W ↔ noted either decreased consumption or no change El Ati 16 W ↔ in consumption. Ibrahim 9M&5W ↔ Collectively, the literature indicates that dietary Carbohydrate (%) Adlouni 32 M ↑ changes pertaining to kcal intake, as well as macro- and Al-Hourani 57 W ↔ micro-nutrient intake, may or may not differ over the Bouhlel 9M ↓ period of Ramadan. These differences, or lack thereof, El Ati 16 W ↓ may be responsible for the discrepancies in health- Maughan 59 M ↓ related outcomes across studies. Rakicioğlu 21 W ↓ Regarding anthropometric variables, body mass index Protein (%) Adlouni 32 M ↑ (BMI) may or may not decrease in response to Ramadan El Ati 16 W ↑ fasting. See Table 2 for a presentation of available Maughan 59 M ↑ findings. Al-Hourani 57 W ↔ The majority of findings related to total cholesterol, Bouhlel 9M ↔ low density lipoprotein cholesterol (LDL-C), and high Rakicioğlu 21 W ↔ density lipoprotein cholesterol (HDL-C) are mixed. See Fat (%) Bouhlel 9M ↑ Table 3 for a presentation of available findings. Also, El Ati 16 W ↑ heterogeneous findings exist regarding whether Rama- Khaled 276 W ↑ dan fasting decreases [29,30] or increases the LDL- Rakicioğlu 21 W ↑ C/HDL-C ratio. Finally, the TC/HDL-C ratio appears to Adlouni 32 M ↔ decrease during Ramadan [13,29,30,32]. Al-Hourani 57 W ↔ Heterogeneous findings have been noted regarding Maughan 59 M ↔ other biochemical outcomes during Ramadan fasting, 1 Energy intake at day 14 increased compared to pre-fasting values (p < 0.05). including blood triglyceride and blood glucose levels. Energy intake at day 28 did not change compared to pre-fasting values See Table 4 for a presentation of available findings. (p > 0.05). Little consensus exists regarding blood count out- 2 Energy intake increased to an extent that approached significance (p = 0.058). comes during Ramadan. Hematocrit has been reported M = men; W = women. to either decrease [28,30], increase , or stay the same [34-36]. The majority of studies found that hemo- globin levels do not change [18,35-37], but decreased Table 1. Similarly heterogeneous findings exist regarding both saturated fat consumption and monounsaturated Table 2 Effects of Ramadan fasting on body mass index fat consumption during Ramadan. Regarding saturated Reference Subjects Effect fat, studies have reported decreased consumption , El Ati 16 W ↔ increased consumption , and no change in con- Ibrahim 9M&5W ↔ sumption [14,24]. Some studies noted increased mono- Kassab 44 W ↔ unsaturated fat consumption during Ramadan [25,26], Maislos 16 M & 8 W ↔ while others noted no change [14,24]. However, there Maughan 59 M ↔ appears to be a consensus that polyunsaturated fat con- Rakicioğlu 21 W ↔ sumption does not change during Ramadan [14,24-26]. Yucel 21 M & 17 W ↔ Also, trans fatty acid consumption was reported to Al-Hourani 57 W ↓ increase during the fast. Bouhlel 9M ↓ Aside from macronutrients, vitamins and minerals are Fakhrzadeh 50 M & 41 W 1 generally consumed in similar amounts during Rama- Khaled 276 W ↓ dan. Examples include: thiamin ; niacin folate Salehi 28 M ↓ ; vitamin C [14,27]; vitamin E [14,27] calcium ; Ziaee 41 M & 39 W ↓ magnesium ; potassium ; and zinc. Vitamin 1 Body mass index decreased in men (p < 0.05) but did not change in women A consumption was noted to increase during Ramadan (p > 0.05).. Also, Rakicioğlu and colleagues found that M = men; W = women. Trepanowski and Bloomer Nutrition Journal 2010, 9:57 Page 4 of 9 http://www.nutritionj.com/content/9/1/57 Table 3 Effects of Ramadan fasting on blood lipids Table 4 Effects of Ramadan fasting on blood triglycerides Outcome Reference Subjects Effect and blood glucose Total Cholesterol Fedail 20 M & 4 W ↑ Outcome Reference Subjects Effect Khaled 276 W ↑ Triglycerides Kassab 44 W ↔1 Aksungar 12 M & 12 W ↔ Aksungar 12 M & 12 W ↔ Bernieh 7M&4W ↔ Bernieh 7M&4W ↔ El Ati 16 W ↔ El Ati 16 W ↔ Kassab 44 W ↔ Fedail 20 M & 4 W ↔ Ibrahim 9M&5W ↔ Maislos 16 M & 8 W ↔ Maislos 16 M & 8 W ↔ Ramadan 13 M ↔ Rakicioğlu 21 W ↔ Salehi 28 M ↔ Ramadan 13 M ↔ Ziaee 41 M & 39 W ↔ Sarraf-Zadegan 22 M & 28 W ↔ Adlouni 32 M ↓ Ziaee 41 M & 39 W ↔ Fakhrzadeh 50 M & 41 W ↓ Adlouni 32 M ↓ Ibrahim 9M&5W ↓ Fakhrzadeh 50 M & 41 W ↓ Glucose Bernieh 7M&4W ↔ Salehi 28 M ↓ Bouhlel 9M ↔ LDL Cholesterol Ziaee 41 M & 39 W ↑ El Ati 16 W ↔ Aksungar 12 M & 12 W ↔ Kassab 44 W ↔ Maislos 16 M & 8 W ↔ Maislos 16 M & 8 W ↔ Sarraf-Zadegan 22 M & 28 W ↔ Maughan 48 M ↔ Adlouni 32 M ↓ Adlouni 32 M ↓ Fakhrzadeh 50 M & 41 W ↓ Ibrahim 9M&5W ↓ HDL Cholesterol Adlouni 32 M ↑ Salehi 28 M ↓ Aksungar 12 M & 12 W ↑ Ziaee 41 M & 39 W ↓ Fakhrzadeh 50 M & 41 W ↑ 1 Blood triglycerides increased in obese women to an extent that approached Maislos 16 M & 8 W ↑ significance (p = 0.05), as cited by authors. Blood triglycerides did not change in lean women (p > 0.05). Sarraf-Zadegan 22 M & 28 W ↔ M = men; W = women. Ziaee 41 M & 39 W ↓ M = men; W = women. corpuscular hemoglobin concentration (MCHC) levels increased in weight-lifters that ceased exercise during levels have also been reported. Maughan and col- Ramadan ; in contrast, the same group noted that leagues reported that hemoglobin levels decreased MCHC levels did not change in weight-lifters that con- in soccer players who were tested in the morning after tinued to resistance train three sessions per week for 90 two weeks of fasting; however, these levels returned to minutes per session. Other studies have reported that their pre-Ramadan values after two more weeks of fast- MCHC levels do not change during the fast [37,39]. ing. Contrastingly, the same group reported that hemo- Two studies to date have examined the effects of globin levels decreased in soccer players who were Ramadan fasting on oxidative stress and antioxidant sta- tested in the afternoon after both two and four weeks of tus. Ibrahim and coworkers observed a reduction in fasting. Serum iron levels have been found to either malondialdehyde (MDA) concentrations in red cells, decrease or remain unchanged during Rama- while no changes were noted regarding levels of either dan fasting. Ramadan and colleagues reported that serum MDA or plasma protein-bound carbonyls. No serum iron levels decreased in sedentary men but did change was noted in the concentration of glutathione or not change in physically active men. Transferrin the activities of glutathione peroxidase and catalase in levels have been reported to increase during Ramadan red cells. Plasma levels of ß-cryptoxanthin and total car-. Maughan and colleagues reported that serum ferri- otenoids significantly decreased during Ramadan fasting, tin levels decreased after two weeks of Ramadan fasting and plasma levels of vitamin C, b-carotene, lycopene, in subjects tested in the morning ; however, these and lutein were non-significantly reduced. No changes levels returned to pre-Ramadan values after two addi- were noted regarding plasma levels of a-tocopherol, tional weeks of fasting. Contrastingly, the same group g-tocopherol, retinol, a-carotene, and zeaxanthin. noted that serum ferritin levels did not change at any Chaouachi and coworkers reported that subjects time point in subjects who were tested in the afternoon experienced an increase in blood levels of vitamin A and. Tayebi and coworkers reported that mean a decrease in blood levels of vitamin E during Ramadan. Trepanowski and Bloomer Nutrition Journal 2010, 9:57 Page 5 of 9 http://www.nutritionj.com/content/9/1/57 There are mixed results regarding the effects of Rama- diet can be viewed as a variant of vegetarianism and dan fasting on blood pressure. Studies have reported also as a form of DR. that neither resting systolic pressure nor resting diastolic Daily kcal intake may or may not decrease during the pressure changes during the fast [35,41], but decreases fasting periods [42-46]. In terms of percentage of energy in both variables have also been reported. One consumption, there appears to be a consensus that study found that systolic (but not diastolic) pressure Greek Orthodox Christian fasting increases carbohydrate during steady-state aerobic exercise increased during intake and decreases fat intake [42-44,46]. Also, the Ramadan. amount of protein intake relative to carbohydrate and To summarize, little consensus exists regarding the fat intake may or may not decrease during Greek Ortho- effects of Ramadan fasting on the majority of health- dox Christian fasting. When expressed as an abso- related outcomes. Many of the discrepancies regarding lute amount, both total fat and total protein intake findings are likely due to differences between studies in decrease during the fasting periods, while total carbohy- daily fasting time, smoking status, medication consump- drate intake does not change. Both saturated fat tion, and/or dietary norms. Although most manuscripts and trans-fatty acid consumption decrease during fasting report daily fasting time, many do not report one or periods, and monounsaturated fat consumption does not more of the other confounding variables. Future change [43,44,46]. Additionally, polyunsaturated fat con- research should be designed so as to eliminate - or sumption may or may not decrease during Greek minimize the effect of - as many confounding variables Orthodox Christian fasting [43,44,46]. as possible. For example, future studies should likely In terms of vitamin and mineral intake, both riboflavin exclude smokers from the subject population so that the and calcium [43,44,46,47] intake decrease during effects of daytime smoking cessation are not conflated fasting periods. On the other hand, magnesium intake with the effects of the fast itself. Alternatively, smokers increases during these periods [43,47]. The intake of the should be allocated to a separate group of fasters, which following vitamins and minerals do not appear to may then be compared to non-smokers undergoing the change during fasting periods: vitamin A [43,44,46]; fast. The same care should be taken to control for other thiamin ; niacin ; vitamin C [43-45] (Sarri, potential confounding variables, as only through such 2009); vitamin E [43,44,46]; phosphorus ; potassium careful control within the research design will reliable [43,47]; and zinc. Some studies found that folate results pertaining to the health effects of Ramadan fast- consumption increases during Greek Orthodox Chris- ing be obtained. tian fasting [43,44], while another study noted no differ- ence in consumption between fasters and non-fasters Greek Orthodox. Sodium intake has been found to either decrease There are three principal fasting periods for Greek or not change during the fasts. Also, vitamin Orthodox Christians. During the Nativity fast (40 days), B12 may or may not decrease during Greek Orthodox fasters abstain from dairy products, eggs, and meat Christian fasting [43,44,46]. every day. Also, fasters abstain from fish and olive oil on In terms of anthropometric outcomes, BMI may or Wednesdays and Fridays during this period. During Lent may not decrease during fasting periods [42,46]. Also, (48 days), fasters abstain from dairy products, eggs, and the average body mass of Greek Orthodox Christian meat every day. Additionally, fasters abstain from olive monks was observed to decrease during a fasting week oil on weekdays during this period and abstain from fish by an amount that approached significance (p = 0.059) every day except for March 25th and Palm Sunday. Dur-. ing the Assumption (15 days), fasters abstain from dairy Regarding biochemical outcomes, both total choles- products, eggs, and meat. Also, fasters abstain from terol and LDL-C levels decrease during fasting periods olive oil on weekdays during this period and abstain [42,43,46]. One study reported a decrease in HDL-C from fish every day except for August 6th. In addition to levels , while other studies reported no change these principal fasts, every Wednesday and Friday that [43,46]. The LDL-C/HDL-C ratio does not change dur- falls outside of a principal fasting period calls for the ing Greek Orthodox Christian fasting. One study proscription of cheese, eggs, fish, meat, milk, and olive noted a decrease in TC/HDL-C ratio , while another oil. Exceptions to these proscriptions occur on the week study noted no change. Regarding triglyceride following Christmas, Easter, and the Pentecost. Collec- levels, one study found an increase during fasting peri- tively, dietary consumption is restricted for 180 - 200 ods , while other studies noted no change [42,46]. days each year. The Greek Orthodox Christian diet con- Besides blood lipids, Greek Orthodox Christian fasting sists largely of bread, fruits, legumes, nuts, seafood, may or may not decrease blood glucose levels [42,43,46]. snails, and vegetables during fasting periods. This Also, several studies have reported that fiber intake Trepanowski and Bloomer Nutrition Journal 2010, 9:57 Page 6 of 9 http://www.nutritionj.com/content/9/1/57 increases during fasting periods [42-45,47], although one which Daniel resolved not to defile himself with the study reported no change. royal food and wine and requested permission to con- Sarri and coworkers compared other hematological sume nothing but vegetables (pulse) and water for 10 changes in fasters and non-fasters during the Christmas days. Later in the same book (Daniel 10:2-3 NIV), fasting period : the authors reported a relative increase Daniel again followed a 21 day period of fasting, during in serum ferritin levels, a relative decrease in MCHC levels, which time he ate no choice food (meat or wine). Based and no relative change in levels of hemoglobin, serum iron, on these two passages, a modern day Daniel Fast and transferrin. The authors also reported that the non- involves ad libitum intake of specific foods, but the food fasters’ hematocrit values significantly declined compared choices are restricted to fruits, vegetables, whole grains, to the fasters’ hematocrit values. Despite this decrease, the legumes, nuts, seeds, and oil. This plan resembles a non-fasters’ hematocrit end values were actually higher vegan diet, which has been reported to yield health- than the fasters’ hematocrit end values, and both end enhancing properties [48,49]. values were within normal ranges. Like Greek Orthodox Christian fasting, the Daniel Fast There are conflicting findings on the effects of Greek may be viewed as a form of DR. However, unlike the Orthodox Christian fasting on blood pressure. One Greek Orthodox Christian fasts, or a simple vegetarian study found that systolic blood pressure increased dur- diet, a Daniel Fast is much more stringent; this is ing fasting periods , while another study found no because refined foods, white flour, preservatives, addi- change in blood pressure when fasters were compared tives, sweeteners, flavorings, caffeine, and alcohol are with non-fasters. One study reported that non- each forbidden. Nonetheless, because individuals tradi- fasters’ diastolic blood pressure decreased significantly tionally follow the Daniel Fast for strict religious pur- during fasting periods when compared to the changes in poses in an attempt to become closer to God during a fasters’ diastolic blood pressure , while another time of extended prayer, anecdotal reports and prelimin- study reported that fasters’ diastolic blood pressure did ary scientific study have indicated excellent compliance. not change during fasting periods. The Daniel Fast is most commonly partaken for 21 Although no study to date has examined oxidative days, although longer (e.g., 40-day) and shorter (e.g., 10- stress in response to Greek Orthodox Christianity fast- day) fasts have been observed. While the Daniel Fast ing, a recent study measured serum antioxidant levels can be partaken at any time of the year, it is often prac- before and after the Nativity fast. This investigation ticed during the month of January in order to begin the found that serum retinol, the retinol:TC ratio, serum a- New Year through fasting and prayer. tocopherol, and the a-tocopherol:TC ratio each To test the health benefits of the Daniel Fast within a decreased following this fast. laboratory-based protocol, we recently enrolled men and In sum, Greek Orthodox Christian fasting appears to women of varying age (20-62 yrs) into a 21-day Daniel lower body mass. Carbohydrate intake appears to Fast. Pre and post intervention, subjects underwent increase, while the intake of protein, total fat, saturated a variety of laboratory tests including measures of body fat, and trans fatty acids decrease during fasting periods. weight and body composition (measured via dual energy Both total and LDL-C decrease, although the LDL-C/ x-ray absorptiometry), resting blood pressure and heart HDL-C ratio does not appear to change. Fiber intake rate, fasting blood measures of oxidative stress, inflam- increases during fasting periods, which may partly mation, blood lipids, insulin, and glucose. Subjects also explain the change in serum lipids. The intake of most rated their compliance to the fast, as well as their overall vitamins and minerals does not appear to change during mood and satiety during the 21-day fasting period. these periods, although riboflavin and calcium intake We noted excellent compliance to the fast (> 98%), each appear to decrease, and magnesium intake appears as well as both excellent results for overall mood and to increase. Also, one investigation reported increases in satiety (7.9 ± 0.2 using a 10 point scale). As expected, serum retinol and serum a-tocopherol. More research a reduction was noted in the following variables from remains to be performed on hematological variables and the seven days prior to starting the fast to the final blood pressure during fasting periods due to both the seven days of the fast: total kcal, protein, total fat, lack of previous research and the mixed findings. More- saturated fat, trans fat, and cholesterol. Also, an over, given that each fasting period has unique durations increase was noted in the following: carbohydrate, and dietary precepts, future research should examine fiber, and vitamin C. these fasting periods both separately and collectively. The following variables related to cardiovascular dis- ease risk were significantly lower following the fast as Daniel Fast compared to before the fast: total cholesterol, LDL-C, A popular fast practiced by Christians, the Daniel Fast SBP, and DBP. Insulin, HOMA-IR, and C-reactive pro- derives from the Biblical story of Daniel (1:8-14 NIV), in tein were all lowered to a clinically meaningful extent, Trepanowski and Bloomer Nutrition Journal 2010, 9:57 Page 7 of 9 http://www.nutritionj.com/content/9/1/57 but this decrease failed to reach statistical significance. Only one study to date has examined the health- Due to the drastic decrease in total cholesterol (~19%), related effects of a Daniel Fast. This study reported HDL-C was lower after the fast as compared to before meaningful improvements in blood pressure, blood the fast (55.65 ± 2.50 vs. 47.58 ± 2.19 mg·dL -1 ). lipids, and biomarkers of oxidative stress. Moreover, Although body weight and body fat were reduced insulin, HOMA-IR, and C-reactive protein were all low- slightly, no significant difference was noted. In regards ered to a clinically meaningful extent. However, the to measures of blood antioxidant status and oxidative study also noted an undesirable lowering of HDL-C. stress, a significant increase was noted in Trolox Equiva- Future work should modify food choices in an effort to lent Antioxidant Capacity and nitrate/nitrite (a surrogate maintain HDL-C. Also, future research should examine marker of nitric oxide), while a significant decrease was the tolerability and health-related effects of partaking in noted in MDA (manuscript in progress). a Daniel Fast for longer durations. The above findings demonstrate that a 21-day Daniel Collectively, the religious fasts featured in this review Fast can significantly improve several markers of overall emphasize the importance of quality dietary intake in health, particularly those related to cardiovascular and eliciting favorable effects on health. Both the Daniel Fast metabolic disease. Larger scale, randomized studies are and the Greek Orthodox Christian fasts are associated needed to extend these preliminary findings. Future stu- with many favorable health outcomes despite the fact dies should possibly consider extending the duration of that fasters can eat as much as they desire. On the other the fast, as well as modifying food choices in an effort hand, whether or not Ramadan fasting elicits favorable to maintain or improve HDL-C levels. health outcomes appears to greatly depend on the food choices of the fasters. This is not to suggest that the Overall Summary and Conclusions quantity of food intake has no bearing on health; hun- Comparisons between different studies of Ramadan fast- dreds of studies have demonstrated the virtue of ing are difficult due to several confounding variables. restricting kcal consumption. Rather, these religious Daily fasting time is highly dependent upon the time of fasts reaffirm the position that one can improve his or the seasonal year that Ramadan occurs as well as the her diet without being compelled to reduce food intake. location’s latitudinal distance from the equator. The Diet plays an integral role in the religious customs of percentage of subjects who smoke, consume oral medi- a variety of faiths. For many religions, this role is mani- cations, and/or receive intravenous fluids can greatly fested in the form of specialized fasting periods. affect a study’s findings, because these activities are for- Although religious fasting is often a time of great spiri- bidden during the daylight hours of Ramadan. Finally, tual growth, it can also be a time of great improvement food choices and eating habits can vary greatly between to one’s physical health. This review highlights the different cultures. Collectively, these confounding vari- potential of different religious fasts as forms of dietary ables likely explain the lack of consensus regarding the modification. It is our hope that the information pro- effects of Ramadan fasting on the majority of health- vided within this review will initiate the design and per- related biomarkers observed in this review. To the formance of future investigations focused on the health extent that it is possible, future work should attempt to benefits of religious fasting. minimize the effect that these confounding variables have on findings. Acknowledgements During the Greek Orthodox Christian fasting periods, Support for this work was provided by the University of Memphis. the daily intakes of protein, fat, saturated fat, trans-fatty acids, riboflavin, and calcium are reduced. Also, these Authors’ contributions JFT was chiefly responsible for reviewing the relevant literature and writing fasts are associated with lower levels of the following: this article. RJB provided the article outline and assisted with the writing and body mass, total cholesterol, LDL-C, and the LDL-C/ editing of this article. Both authors read and approved the final manuscript. HDL-C ratio. Intake of fiber and carbohydrate Competing interests (expressed as a percentage of macronutrient intake) The authors declare that they have no competing interests relative to the increase, while no changes occur regarding the intake of material presented within this article. monounsaturated fat as well as most vitamins and Received: 6 July 2010 Accepted: 22 November 2010 minerals. To date, only a few investigations have exam- Published: 22 November 2010 ined the health-related effects of these fasting periods. Clearly, more work remains to be performed, particu- References larly regarding hematological and blood pressure vari- 1. Spindler SR: Caloric restriction: From soup to nuts. Ageing Res Rev 2009, 9(3):324-353. ables. Also, each principal fasting period should be 2. Imai S: SIRT1 and caloric restriction: an insight into possible trade-offs studied both separately and aggregately due to their dif- between robustness and frailty. 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