Effect of Ramadan on glucose levels, serum lipid profile, and blood pressure among fasting and nonfasting medical students in a public university of Karachi

Objective: The objective of this study was to assess the effect of Ramadan fasting on blood pressure, fasting glucose, lipid profile, and serum proteins between non-Muslim and fasting Muslim students. Methodology: The study was conducted on undergraduate medical students of a medical university of Karachi. Participants were invited for data collection: in the last 10 days of Shaban, Ramadan, and Shawwal. Along with blood pressure, height, and weight were measured and a sample of 10 cc blood was also drawn in each visit. Blood samples were analyzed for glucose, lipid profile, and serum protein. Two samples, “t”-test and repeated measure design analysis of variance were utilized for statistical analysis. Results: Sixty Muslims and 15 non-Muslim students completed all the three visits. Seventy-five percent were females. Mean systolic blood pressure reduced significantly in Ramadan. Mean diastolic blood pressure reduced noticeably in Ramadan and Shawwal for non-Muslim students and minor changes occurred in Muslim students. Even though the fasting blood sugar increased insignificantly from Shaban to Ramadan in the total sample, but the increment among Muslim students showed a significant increase. The mean cholesterol value of Muslim students significantly increased in Ramadan but decreased in Ramadan for non-Muslim students. The mean value of low-density lipoprotein increased significantly in Ramadan for Muslim students but decreased in Ramadan for non-Muslim. The mean values of triglyceride showed a significant reduction from Shaban to Ramadan and then increased in Shawwal. Conclusion: The study revealed that the environment of Ramadan was helpful to the non-Muslim students more than the Muslim students, with respect to the biochemical parameters.

Key-words:

Medical University - Muslim and non-Muslim students - Ramadan environment - Ramadan fasting

Introduction

Fasting is a compulsory obligation for each healthy Muslim adult man and woman in Ramadan, except sick, traveling, pregnant, breastfeeding, menstruating, or debilitated individuals. More than a billion Muslims in the world who are 15 years and older practice the fasting during this month. Fasting period in Ramadan during summer ranges from 14 to 15 h in Karachi, Pakistan. For most of the fasting people, the number of meal is reduced to two, once at Sahoor and another at Iftar. The dishes of Iftar are mostly comprised fried items and fruits. It provides about 90% of the daily requirement of calories.[[1]] Ramadan also affects the sleep pattern due to extra night prayers and early wake-up for eating Sahoor, and consequently shorten the nighttime sleep.[[2]] Most of those who miss sleeping compensate for it by taking a nap in the afternoons. In addition, the daytime regular exercises are reduced due to fasting and engagements of religious activities at night.[[3]] Literature indicates that changes in eating habits and timing of meals, sleeping patterns, and physical activities may change the physiological and behavior attitude during the month of Ramadan.[[4]]

Many studies have been conducted to determine the effect of Ramadan fasting. Most of them were conducted on diabetic patients.[[5]],[[6]],[[7]],[[8]] Some studies were performed on nondiabetics patients[[9]],[[10]],[[11]],[[12]] and some on healthy controls.[[13]],[[14]] Some studies were conducted on Muslim students.[[15]],[[16]],[[17]],[[18]],[[19]],[[20]] However, studies comparing the environmental effects of Ramadan on non-Muslim and fasting Muslim students are scarce. Hence to compare the effect of the month of Ramadan of non-Muslim and fasting Muslim students of a medical school in Karachi, this study was organized. The objective of the study was to assess the effect of Ramadan fasting on blood pressure, fasting glucose, cholesterol, triglyceride, high-density lipid, low-density lipid, serum proteins, weight, and body mass index (BMI) between non-Muslim and fasting Muslim students.

Methodology

The study was approved by the Institutional Review Board of Jinnah Sindh Medical University (JSMU) and was funded by the Research Funding Committee of JSMU. Participants of this study were the students of JSMU, Karachi. The principal investigator has visited all the classes from 1st to 5th year of Bachelor of Medicine and Bachelor of Surgery (MBBS) and briefed about the project through multimedia and invited to register. Willing students were informed that they would visit three times; in the last 10 days of each of 3 months (Shaban, Ramadan, and Shawwal). Sixty Muslims and 15 non-Muslims completed all the three visits. Blood pressure was measured twice from each subject in all the three visits. Height, weight, waist, and hips measurements were also taken. A fasting blood sample (12 h fasting) of 10 cc was collected by trained phlebotomists in the pathology laboratory of Jinnah Postgraduate Medical Center and JSMU Diagnostic Laboratory and Blood Bank. The blood samples were collected in two tubes, one for blood glucose measurement and other for serum separation, with number and participant's name. All the samples were analyzed for (1) glucose, (2) cholesterol, (3) triglyceride, (4) uric acid, (5) high-density lipoprotein (HDL)-C, (6) low-density lipoprotein (LDL)-C, and (7) serum proteins. A questionnaire was also administered to each participant for demographic information, systemic diseases, physical activities, and sleeping habits in each visit. It was announced in the beginning that a Muslim student must intend to fast 20 days to be enrolled as fasting Muslim. The number of days the participants has fasted during the Ramadan period and the number of days of Taraweeh prayers were asked in the last visit. All the Non-Muslims were hostel residents. The blood samples in Ramadan were arranged before the Iftar. Statistical Package for Social Sciences (SPSS version 20; SPSS Inc., Chicago, IL, USA) was used to enter and analyzed the data obtained. Two independent samples “t”-test was utilized to compare the mean values of height, weight, waist, and hip measurements of Shaban between Muslim and non-Muslim students. Repeated measure design analysis of variance with visits as within-subjects and religion and BMI as co-factors was used to analyze the mean values of systolic and diastolic blood pressures, glucose level, cholesterol, triglyceride, HDL, LDL, very-low-density lipoprotein (VLDL), and serum proteins of the three visits.

Results

Sixty fasting Muslim and 15 non-Muslim students completed all the three visits. Seventy-five percent were females and about 70% of them were aged between 19 and 22 years. Eighty percent of the participants were Muslims [[Figure 1]].

Figure 1: Descriptive statistics of gender, age-group and religion

The mean values of the Muslim and non-Muslim students' height, weight, waist, and hips measurements are shown in [[Figure 2]]. The mean value of the heights of non-Muslim students in the month of Shaban was little more than Muslim students (161.37 cm vs. 160.79 cm). The mean values of weight, waist, and hips measurements of Muslim versus non-Muslim students were 57.17 kg versus 54.47, 71.85 cm versus 69.69 cm, and 92.42 versus 87.58, respectively. The mean differences in all the four parameters mentioned above were statistically insignificant (P > 0.05).

Figure 2: Mean value of height, weight, waist and hips

[[Table 1]] shows the mean ± standard deviation (SD) of systolic blood pressure (SBP), diastolic blood pressure (DBP), fasting blood sugar (FBS), and protein level for Muslim, non-Muslim students and total sample in all the three visits. It also indicates the significant effects of religion (Muslim and non-Muslim) and initial BMI in changing the mean values of the aforementioned parameters. [[Figure 3]] shows the pattern of changes of these parameters for Muslim and non-Muslim students. In Shaban, the mean SBP of both the groups were almost the same (111.0 [M] vs. 111.3 [N]). It reduced noticeably in Ramadan (107,4 [M] vs. 105.0 [N]) and increased slightly in Shaban (108.9 [M] vs. 105.5 [N]). It should be noticed that reduction in SBP was more in Non-Muslim students than Muslim students. This is linked to the BMI measurements in Shaban, which showed a significant effect (P < 0.0001) in reducing the SBP.

Table 1: Descriptive statistics with comparisons between Muslim and non-Muslim in three visits of systolic and diastolic blood pressures, fasting blood sugar and protein

Figure 3: Mean values of systolic blood pressure, diastolic blood pressures, fasting blood sugar and protein of Muslim and non-Muslim students in three visits

The mean DBP of Muslim students were almost the same in three visits. However, it reduced noticeably in Ramadan and Shawwal for non-Muslim students (73.4 [Shaban], 71.6 [Ramadan], 70.6 [Shawwal]). Nevertheless, the changes in mean DBP in the total sample were insignificant (P > 0.05). However, the initial BMI showed a significant effect in the changes of DBP (P = 0.001).

Mean FBS increased for both Muslim and non-Muslim students in the end of Ramadan (Muslim [69.7 (Shaban), 81.8 (Ramadan)], non-Muslim [66.0 (Shaban), 68.1 (Ramadan)]). However, it reduced little bit for Muslim students but kept an upward trend for non-Muslims. But changes in the mean value of Muslim students were more conspicuous than non-Muslim students [[Figure 3]]. There was no significant difference in all the three mean values of the total sample (P > 0.05). The religion factor (Muslim/non-Muslim) showed a significant effect in changing the mean values (P = 0.035). Mean protein values decreased in the month of Ramadan and then increased in the month of Shawwal for both Muslim and non-Muslim students. However, these changes were marginal and were statistically insignificant (P > 0.05). Religion and BMI also did not show any statistically significant changes.

[[Table 2]] shows the mean ± SD of total cholesterol, HDL, LDL, VLDL, and triglyceride, along with significant values of the effects of religion and BMI. The changes of these parameters in the three readings are shown in [[Figure 4]]. The mean cholesterol value of Muslim students significantly increased in Ramadan (150.3 [Shaban], 162.7 [Ramadan]), but dropped back significantly in Shawwal (136.9). However, the mean cholesterol value of non-Muslim students decreased in Ramadan (151.1 [Shaban], 132.3 [Ramadan]), but increased in Shawwal (137.9). These changes did not show any statistical significance. For the total sample, only the mean value of Shawwal decreased significantly from Ramadan's mean value (159.0 vs. 137.1). The religion and BMI did not show any significant effect (P = 0.329 and P = 0.380, respectively). Minor and insignificant changes have appeared in the mean values of HDL in all three readings. Mean value of LDL increased significantly in Ramadan for Muslim students and reversed back significantly in Shawwal (93.1 [Shaban], 100.3 [Ramadan], 76.2 [Shawwal]). However, the changes for non-Muslim were in the opposite direction, decreased in Ramadan, and increased in Shawwal. However, there was an increase in mean LDL value in Ramadan and then decreased in mean LDL value in Shawwal for the total sample. These changes were statistically insignificant for non-Muslim and total samples. The mean value of VLDL showed continuous reduction in Ramadan and Sahwwal from Shaban. However, only the mean value of Shawwal showed a significant reduction from Shaban (24.6 [Shaban], 15.9 [Ramadan], 13.1 [Shawwal]). The same trend was seen for non-Muslim students. Even though the reduction from Shaban to Ramadan was quite noticeable, but it was not statistically significant due to the low number of readings for this parameter. The total sample showed the same trends of continuous reduction, but none of them were statistically significant. Religious and BMI factors also did not show any effect in the change of VLDL values. The mean values of triglyceride showed a significant reduction from Shaban to Ramadan and then increased in Shawwal among Muslim, non-Muslim students, and total sample. None of the changes showed statistical significance. Religion and BMI also did not show any effect in the changes of mean values. The mean values of triglyceride of non-Muslim students were noticeably higher than Muslim students.

Table 2: Descriptive statistics with comparisons between Muslim and Non-Muslim in three visits of cholesterol, high density lipoprotein, low density lipoprotein, very low density lipoprotein and triglyceride level

Figure 4: Mean values of cholesterol, high-density lipoprotein, low-density lipoprotein, very-low-density lipoprotein and triglyceride of Muslim and non-Muslim students in three visits

Discussion

As far as the studies are concerned, this is the first study to discuss the effect of the month of Ramadan between fasting Muslim and non-Muslim students of a medical university. Non-Muslim students are fewer than Muslim students in the sample. It is because: (1) non-Muslim students are fewer in number in the university as compared to Muslim students and most of them are transferred students from interior Sindh, (the province of Pakistan in which Karachi is the capital), live in students' hostels; (2) non-Muslim students did not take that much interest due to religious inclination of the study. However, the percentage of non-Muslim in the sample was well-above of the percentage of non-Muslim in the university and in the Pakistani population.[[20]]

No significant difference was observed in the height, weight, waist, and hips measurements between fasting and nonfasting students in the first visit. Therefore, those two groups were comparatively equivalent and did not need any initial adjustments. However, mean values of weight, waist, and hips measurements of non-Muslim were a little bit shorter than Muslim students, even though the former students were a little bit taller than later students. It is because almost all the non-Muslim students belonged to the Hindu religion and expected to be vegetarians. A meta-analysis showed that vegetarians showed lesser weight than nonvegetarians.[[21]]

This study showed that the systolic and DBPs reduce insignificantly from Shaban to Ramadan. However, the reductions were faster among non-Muslim than Muslim students. Literature shows that there is a positive correlation of blood pressures with BMI.[[22]] Since the mean weight of non-Muslim students was lower than Muslim students with higher mean height. Therefore, BMI of non-Muslim students was lower than Muslim students, and hence faster reduction of blood pressures of non-Muslim could also be due to lower BMI along with the lesser frequency of food intake. Even though the FBS increased insignificantly from Shaban to Ramadan in the total sample, but the increment among Muslim students was significant. Furthermore, it should also be noted that increment in FBS among non-Muslim students in Ramadan was comparatively quit lower than Muslim students. Consequently, P value related to religion showed a significant difference. It is usual practice that sugar consumption increases in Ramadan, especially during Iftar dinner.[[23]] Therefore, there is a high probability that the blood sugar level will increase more among Muslim students by the end of Ramadan than non-Muslim students.

Cholesterol level increased significantly from Shaban to Ramadan among Muslim students but decreased insignificantly among non-Muslim students. Even though the consumption of fat increases during Ramadan,[[23]],[[24]] other studies have showed that there is no significant change in the blood cholesterol level from Shaban to Ramadan[[17]],[[18]] or sometimes it decreased.[[19]] Nevertheless, if only female students are considered, then there is a significant increase in the cholesterol level[[23]] which agrees with this study. Since 75% of our participants were females, therefore it follows Lamri-Senhadji et al.[[24]] studies. There is no significant change in HDL values for both Muslim and non-Muslim students. However, there is a significant increase in the total sample in Shawwal. Khan et al.[[17]] also showed that there was a significant increase in HDL value in Shawwal. Muslim students showed a significant increase in mean LDL, which agrees with Khan et al.,[[17]] but other studies[[18]],[[23]] showed that there is no change in LDL values during and after Ramadan among young university students. However, there was a reduction in the mean LDL value of non-Muslim students. The mean triglyceride level reduced from Shaban to Ramadan. Even though the differences were not statistically significant for Muslim or non-Muslim students, but the difference of mean values of among non-Muslim students was noticeable. This downward trend of mean triglyceride from Shaban to Ramadan is agreed by Khan et al.,[[17]] Mansoor[[19]] and female data of Ongsara et al.[[18]]

It should be noted that all the non-Muslim students were hostel residents. During the Ramadan period, the kitchens of the hostel do not serve food during daytime; they only serve Iftars, dinners and Sahures. Nonfasting students have to arrange their lunches by themselves. Due to this Ramadan environmental effect, non-Muslim students only eat dinner, because they usually do not wake up early in the morning to eat Sahur meal. Therefore, non-Muslim students spend more time without food as compared to Muslim students, and hence, they affected more during this month. Furthermore, as it is discussed earlier that the amount of protein, fat, and sugar increased during Iftar and dinner as compared to meals of other days. These two factors affected the non-Muslim students more during Ramadan period than Muslim students, and indicators such as blood pressures, cholesterol, LDL, and triglyceride decreased more among non-Muslim students than Muslim students. Furthermore, other indicators were also comparable in both groups. We were not expecting these results, when we hypothesized this study. This factor of not receiving food during the daytime and hostel as the residence of non-Muslim students may be playing a major role for these un-expected results. Therefore, these results should be read with caution. Furthermore, studies should be conducted without these limitations to verify the outcomes.

Conclusion

The study revealed that the environment of Ramadan was helpful to the non-Muslim students more than the Muslim students, with respect to the biochemical parameters.

Authors' contributions

Prof. Nazeer Khan developed the idea, prepared the tools and concept form, supervised the project, analyzed the data, and prepared the manuscript.

Prof. Syed Muhammad Tariq Rafi facilitated to make contact to the Pathology laboratory and arrange the research funding and support in manuscript writing.

Prof. Shameem Siddiqui registered the students and facilitated for blood sample collections. She also read and edited the manuscript.

Dr. Saba Shakeel, Dr. Haseeb-ur-Rahman, and Ms. Wajiha Hasan collected the data, including the filling of questionnaires, physical and blood pressure measurements, and blood sample collections.

Compliance with ethical principles

The study followed the Nuremberg Codes and Declaration of Helsinki for participants' voluntary consent without any constraint and compulsion. The study was approved by the Institutional Review Board of JSMU.

Conflict of Interest

There are no conflicts of interest.

Acknowledgments

The authors are indebted to the University Research Funding Committee, JSMU, for financially supporting this project. We are also thankful to the JSMU students to join this study as volunteers. We are also obliged to Ms. Sara Wahab, Ms. Sumaira Naz, and Mr. Muhammad Farhan for collecting the data.

Financial support and sponsorship

This study was partially supported by the research fund of JSMU, Karachi.

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Publication History

Received: 02 July 2020

Accepted: 22 July 2020

Article published online:
14 July 2022