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May 2015, Volume 65, Issue 5

Management of Co-Morbidities

Lipid Management in Ramadan

Authors: Ines Slim  ( Department of Endocrinology, Farhat Hached University Hospital, Sousse, Tunisia, Ibn Jazzar Faculty of Medicine, University of Sousse, Tunisia. )
Koussay Ach  ( Department of Endocrinology, Farhat Hached University Hospital, Sousse, Tunisia, Ibn Jazzar Faculty of Medicine, University of Sousse, Tunisia. )
Larbi Chaïeb  ( Department of Endocrinology, Farhat Hached University Hospital, Sousse, Tunisia, Ibn Jazzar Faculty of Medicine, University of Sousse, Tunisia. )


During Ramadan fast, Muslims must refrain from smoking, eating, drinking, having sexual activity, and consuming oral medications from sunrise to sunset. It has been previously shown that Ramadan fasting induces favourable changes on metabolic parameters, reduces oxidative stress and inflammation and promotes cardiovascular benefits. Although ill people are exempted from fasting, most patients with chronic diseases are keen on performing this Islamic-ritual. During recent years, Risk stratification and treatment adjustment during Ramadan are well known and structured in several guidelines for patients with diabetes mellitus. Data related to the effect of Ramadan fast on lipid profiles are less known and several controversies have been reported. Here, we focus on lipid profile and lipid management during Ramadan taking into account comorbidities and cardiovascular risk.
Keywords: Ramadan Fasting, Lipids, Management, Risk stratification, Comorbidities.


Fasting in Ramadan, one of the five pillars of Islam, is practiced by millions of Muslims around the world. Every year during the ninth month of the lunar calendar, Muslims refrain from eating, drinking and smoking from sunrise to sunset.1
During the last couple of decades, there has been an increasing interest towards a better understanding of various effects of Ramadan fasting. The studies in question lead to organizing an international conference in 1996 in Casablanca, Morocco where about 50 papers were presented.2 The current opinion highlighted during the meeting was that Ramadan fasting had beneficial effects on health, especially on some cardiometabolic parameters. In agreement, numerous epidemiologic studies that followed the meeting showed positive effects of this Islamic pillar on various parameters in healthy and unhealthy individuals.3
High level of Triglycerides (TG) and low level of high-density lipoprotein cholesterol (HDL) are known to be components of the metabolic syndrome.4 Furthermore, elevated low-density lipoprotein cholesterol (LDL) and decreased HDL, known as dyslipidaemia, is a risk factor for atherosclerosis in coronary artery disease (CAD).5-7
In order to decrease cardiovascular risk, therapeutic strategies usually focus on lowering LDL with scarce effect on HDL increase. Dietary and lifestyle changes remain the only option that helps increase the HDL levels.8 Studying the effects of Ramadan fasting on lipid profile will therefore shed new insight into the impact of such dietary lifestyle changes on Muslim patients who choose to fast.
In this review, we report on the current knowledge of the effects of Ramadan fasting on lipid profile and how patients with dyslipidaemia could be advised its management during the Islamic Holy month.

Lipid Profile during Ramadan Fasting

When mining data related to the effect of Ramadan fasting on lipid profile, several contradictory results were encountered. From the religious aspect, once the day fast is accomplished, there is no restriction on the quantity or quality of food, which is from sunset to sunrise of the following day; this often contributes to the differences noticed in lipid profiles.
The first paper that highlighted the effect of Ramadan fasting on lipid profile in 1978, showed that uric acid levels increase linearly with the duration of fasting, which positively correlates with serum triglycerides but not with cholesterol or phospholipids.9
Several studies involving patients with Type 2 diabetes mellitus (T2DM) reported decreased total cholesterol (TC), triglyceride (TG), very-low-density lipoprotein cholesterol (VLDL), low-density lipoprotein cholesterol (LDL) and apolipoprotein B (Apo-B), a major protein component of LDL, as well as increased high-density lipoprotein cholesterol (HDL) and apolipoprotein AI (Apo-AI)levels after fasting in Ramadan.10 These changes in lipid profile, however, may vary depending on the quality and quantity of food intake as well as the physical activity of the individuals.11
A recent observational study recruiting 1301 Muslim diabetic patients from Qatar, showed that the average levels of TC, LDL and TG were significantly lower during Ramadan as compared to before Ramadan (P<0.001 each).12 This has also been reported for other Muslim populations.13,14
According to Adlouni et al.13 Apo-AI increased on day 8 and day 29 of Ramadan Fasting and remained elevated for up to one month later in comparison to baseline values. However, Apo-B levels were lower during the second and the last week of Ramadan fasting and were maintained at the same level one month after Ramadan fasting.
Al-Shafai demonstrated that lipid levels return to their baseline values 6 weeks post-fasting.14
It has also been shown that combining exercise with Ramadan fasting favourably reduces body mass and body fat, as well as improves lipid profiles and inflammatory status in soccer players.15 These changes could be explained by physiological adaptations during the month of fasting which leads to an increase in reliance on fat as a source of fuel during daytime fasting.16
Feizollahzadeh et al. showed that Ramadan fasting is associated with a significant increase in serum level of adiponectin among men with risk factors of T2DM.17 An increase in serum adiponectin is known to be followed by an improvement in insulin sensitivity18 as well as an enhancement in cell protection against injuries induced by autoimmunity and lipotoxicity.19 Many studies have shown a significant decrease in BMI after Ramadan fasting,15,20,21 suggesting that post-Ramadan adiponectin levels can be attributed to weight loss and decreased body fat. However, weight loss in not observed in all patients as it largely depends on food intake and physical activity during this Holy month.3,20-22 Likewise, it has been reported that physical parameters such as visceral adiposity index or biological markers such as serum apelin-13 levels did not change during Ramadan.23
A recent observational study has shown decreased serum LDL/HDL and TG/HDL ratios. Strikingly, LDL/HDL and especially TG/HDL ratios have been proposed to be better predictors of cardiovascular disease than lipid alone.24 TG/HDL ratio is inversely correlated with protective forms of HDL (large and less dense HDL2 particles) and is associated with insulin resistance.
Putative anti-atherogenic effects of HDL are summarized in Table-1.25

Together, these cellular and molecular effects lead to endothelial protection and prevention against atherosclerotic diseases.
Ramadan positively influences the inflammatory status by decreasing in the pro-inflammatory cytokine (ie, IL-6) concentrations associated with reductions in both high-sensitive C-reactive protein (hs-CRP) and homocysteine.25
Interestingly, independent studies showed that serum level of TG were either unaffected or significantly increased during the fasting period in healthy, obese or diabetic patients.14,24,26-29 Other studies have also shown a decreased level of HDL and/or increased level of LDL.12,31
These discrepancies might be attributed not only to variable diet, physical activity and sleep patterns, but also to number of fasting days, period of daily fasting, time of sampling and genetic differences.32 In fact, some people tend to decrease their levels of activity during Ramadan, while others practice physical activities after dinner or increase their prayer time which is equivalent to moderate physical activity.33 Moreover, dietary habits vary between countries. In obese patients with type 2 diabetes, dietary fat consumption, especially saturated fats (231 kcal/day or 43.25% of total fat 8), is greater than that of non-obese patients (35.84 versus 25.36%). Total cholesterol intake, as well as total and low-density lipoprotein cholesterol concentrations, increased significantly in non-obese patients with type 2 (n= 57) (p <0.03)34 and in type 2 patients with hyperlipidaemia on diet, fibrates or statins.35 Also sleeping habits may be altered and smoking is limited to non fasting time only.
Taken together, the current results suggest it that Ramadan fasting could be a key factor enabling protection against coronary artery disease as it has a positive effect on TG/HDL ratio. Fasting-triggered increase of HDL may therefore constitute one of the best non-pharmacological methods known to date to significantly improve HDL levels.

Lipid Management during Ramadan Fasting

Diabetes Safety: When managing patients with dyslipidaemia, it is important to consider co-morbidities such as type 2 diabetes mellitus, hypertension, cardiovascular diseases and chronic kidney disease. The current knowledge about risk stratification during Ramadan is restricted to diabetic patients with treatment.36 Based on this stratification, we can consider that patients with stable dyslipidaemia and a pre-Ramadan assessment and educational counseling, can be allowed to fast (Flow Chart-1).

Pre-Ramadan Counseling: In patients with lipid abnormalities, fresh statin prescription should be avoided prior to Ramadan because of common effects such as fatigue and/or myalgia that may hamper the ability to fast. Nevertheless, if the use of statin is necessary, they should be started at lowest dose and monitored clinically, and if necessary by checking muscle enzymes. Patients on stable dose of statin may continue their regimen.37
During Ramadan: Due to major diet changes during Ramadan, patients with dyslipidaemia should pay more attention to their life style habits. Healthy diet or lifestyle modifications are recommended as background therapy for the RCTs of cholesterol-lowering drug therapy in the 2013 Lifestyle Management Work Group Guideline for lifestyle recommendations.38 Patients who decide to fast and who would benefit from LDL-C lowering should:
i. Follow a dietary pattern that emphasizes intake of vegetables, fruits, and whole grains; includes low-fat dairy products, poultry, fish, legumes, non-tropical vegetable oils, and nuts; and limits intake of sweets, sugar-sweetened beverages, and red meats.
ii. Adapt this dietary pattern to appropriate calorie requirements, personal and cultural food preferences, and nutrition therapy for other medical conditions (including diabetes).
iii. Achieve this pattern by following plans such as the DASH dietary pattern, the USDA Food Pattern, or the AHA Diet.
iv. Aim at a dietary pattern that achieves 5%-6% of calories from saturated fats.
v. Reduce percent of calories from saturated fat.
vi. Reduce percent of calories from trans-fat.
The above recommendations should be reinforced in patients with dyslipidaemia during Ramadan because in general there are major alterations in food quality and quantity according to cultural habits. Nomani (1997)39 has suggested that when energy is limited, a dietary fat increase from 30% to 36% reduces the breakdown of body protein content including labile LDL cholesterol receptors that are protein in nature.
Another important point that should also be discussed is the timing of meals. Fasting is performed from dawn to dusk. Each day before dawn, Muslims takr a pre-fast meal called Suhur. At Sunset, the fast-breaking meal (generally more caloric than the first one) is called Iftar. Islamic rules encourage the uptake of the Iftar meal as soon as possible upon sunset. This is important as it was recently shown that in healthy subjects, the timing of meals is correlated with overall energy intake.40 The same study has demonstrated in multivariate analyses controlling for age, sex, sleep duration, and timing, that eating more frequently, late timing of the last meal, and a shorter duration between last meal and sleep onset, predicted higher total caloric intake. This suggests that eating close to sleep, could lead to weight gain due to a greater number of eating occasions and higher total daily caloric intake.
Interestingly, between the Iftar meal and sleeping time, the Tarawih prayer, an optional Ramandan-specific prolonged prayer, is usually performed by Muslims. This prayer may be considered as moderate physical activity. More advice for physical activity during Ramadan is presented in Table-2.41

Finally, precaution for lipid assessment should be taken during Ramadan as the 10 hours overnight fasting before blood sampling for lipid levels might be challenging. This is due to the sunset meal timing which may induce errors in interpreting the results.


Significant progress has been accomplished during the couple of last decades in understanding the mechanisms that govern metabolism regulation during Ramdan fasting as well as the strategies to be followed by patients with metabolic diseases who choose to fast prior, during and upon this Holy month. Results from several studies reported controversial effects on lipid profiles depending on fluctuant dietary habits, variable physical activity levels and sleep patterns of the patients involved in the studies. Therefore, in order to achieve beneficial effects in the case of patients with dyslipidaemia who decide to fast, a structured pre-Ramadan risk stratification and counseling should be followed. Additionally, a reinforcement of lifestyle recommendations to prevent cardiovascular risk is needed for patients with dyslipidaemia with or without comorbidities.


We thank Sara Ben Khaled for critically reading the manuscript.


1. Arbesmann R. Fasting and prophecy in pagan and Christian antiquity. Traditio 1949;7:1-71.
2. A Report on First International Congress "Health and Ramadan" Foundation Hassan II, for Scientific and Medical Research on Ramadan. Casablance, Morracco, 1994.
3. Kamoun M, Feki Mnif M, Slim I. Beneficial Effects of Ramadan Fasting on Health. In: zargar AH, Kalra S(eds). Ramadan and Diabetes Care. 1st ed. JAYPEE - The Health Sciences Publisher; 2014.
4. Alberti KG, Zimmet P, Shaw J. Metabolic syndrome-a new world-wide definition. A Consensus Statement from the International Diabetes Federation. Diabet Med 2006 May;23:469-80.
5. Arca M, Montali A, Valiante S, Campagna F, Pigna G, Paoletti V, et al. Usefulness of atherogenic dyslipidemia for predicting cardiovascular risk in patients with angiographically defined coronary artery disease. Am J Cardiol 2007;100:1511-1516.
6. Ali KM, Wonnerth A, Huber K, Wojta J. Cardiovascular disease risk reduction by raising HDL cholesterol - Current therapies and future opportunities. British Journal of Pharmacology 2012;167:1177-1194.
7. Angelantonio ED, Sarwar N, Perry S, Kaptoge S, Ray K, Thompson A. Major lipids, apolipoproteins, and risk of vascular disease. JAMA 2009;302:1993-2000.
8. Hausenloy DJ, Yellon DM. Enhancing cardiovascular disease risk reduction: raising high-density lipoprotein levels. Curr Opin Cardiol 2009;24:473-482.
9. Gumaa KA, Mustafa KY, Mahmoud NA, Gader AM. The effects of fasting in Ramadan. 1. Serum uric acid and lipid concentrations.Br J Nutr 1978;40:573-81
10. Momen HK, Elzouki ANY, Gatie J, El-Mansoury A M,Tashani A. Effect of Ramadan fasting on blood glucose and serum lipid profiles in Libyan diabetic patients. Journal of Science and its Applications 2007;1:14-7.
11. Alkandari JR, Maughan RJ, Roky R, Aziz AR, Karli U. The implications of Ramadan fasting for human health and well-being. J Sports Sci 2012;30(Suppl 1):S9-19.
12. Bener A, Yousafzai MT. Effect of Ramadanfasting on diabetes mellitus: a population-based study in Qatar.J Egypt Public Health Asso 2014;89:47-52.
13. Adlouni A, Ghalim N, Benslimane A, Lecerf JM, Saile R. Fasting during Ramadan induces a marked increase in high-density lipoprotein cholesterol and decrease in low-density lipoprotein cholesterol. Ann Nutr Metab 1997;41:242-249.
14. Al-Shafei AI. Ramadanfasting ameliorates oxidative stress and improves glycemic control and lipid profile in diabetic patients. Eur J Nutr 2014;53:1475-81. doi: 10.1007/s00394-014-0650-y.
15. Hammouda O, Chtourou H, Aloui A, Chahed H, Kallel C, Miled A, et al. Concomitant effects of Ramadanfasting and time-of-day on apolipoprotein AI, B, Lp-a and homocysteine responses during aerobic exercise in Tunisian soccer players. PLoS One 2013;8:e79873.doi: 10.1371/journal.pone.0079873.
16. Khaled BM, Belbraouet S. Effect of Ramadan fasting on anthropometric parameters and food consumption in 276 type 2 diabetic obese women. Int J Diabetes Dev Ctries 2009; 29: 62-68.
17. Feizollahzadeh S, Rasuli J, Kheirouri S,Mohammad Alizadeh M. Augmented Plasma Adiponectin after Prolonged Fasting During Ramadan in Men. Health Promot Perspect. 2014; 4: 77-81.
18. Lihn AS, Pedersen SB, Richelsen B. Adiponectin: action, regulation and association to insulin sensitivity. Obes Rev. 2005;6:13-21.
19. Lee YH, Magkos F, Mantzoros CS, Kang ES. Effects of leptin and adiponectin on pancreatic b-cell function. Metabolism. 2011; 60: 1664-1672.
20. Bouguerra R, Jabrane J, Maâtki C, Ben SL,Hamzaoui J,El Kadhi A, et al. Ramadan fasting in type 2 diabetes mellitus. Ann Endocrinol (Paris). 2006;67:54-9.
21. Shariatpanahi ZV, Shariatpanahi MV, Shahbazi S, Hossaini A, Abadi, A. Effect of Ramadan fasting on some indices of insulin resistance and components of the metabolic syndrome in healthy male adults. Br J Nutr. 2008;100:147-51.
22. Rashed H. The fast of Ramadan: No problem for the well: The sick should avoid fasting. BMJ. 1992;304:521-2.
23. Celik A, Saricicek E, Saricicek V, Sahin E, Ozdemir G, Bozkurt S,et al.Effect of Ramadanfasting on serum concentration of apelin-13 and new obesity indices in healthy adultmen. Med Sci Monit. 2014;20:337-42.
24. Akaber A, Golshan A, Moojdekanloo M, Hashemian M. Does fasting in Ramadan ameliorate Lipid profile? A prospective observational study. Pak J Med Sci. 2014;30:708-711.
25. Calabresi L, Gomaraschi M, Franceschini G. Endothelial protection by high-density lipoproteins: from bench to bedside. Arterioscler Thromb Vasc Biol. 2003;23:1724-1731.
26. Aksungar FB, Topkaya AE, Akyildiz M. Interleukin-6, C-reactive protein and biochemical parameters during prolonged intermittent fasting. Ann Nutr Meta 2007 51: 88-95.
27. Ziaee V, Razaei M, Ahmadinejad Z, Shaikh H, Yousefi R, Yarmohammadi L,et al. The changes of metabolic profile and weight during Ramadan fasting. Singapore Med J. 2006;47:409-414.
28. Nematy M, Alinezhad-Namaghi M, Rashed MM, Mozhdehifard M, Sajjadi SS, Akhlaghi S. et al. Effects of Ramadan fasting on cardiovascular risk factors: a prospective observational study. Nutr J 2012;11:69.
29. Akanji AO, Mojiminiyi OA, Abdella N. Beneficial changes in serum apo A-1 and its ratio to apo B and HDL in stable hyperlipidaemic subjects after Ramadan fasting in Kuwait. Eur J Clin Nutr 2000;54:508-513.
30. Unalacak M, Kara IH, Baltaci D,Erdem Ö, Bucaktepe PGE.Effects of Ramadan fasting on bio- chemical and hematological parameters and cytokines in healthy and obese individuals. Metab Syndr Relat Disord 2011;9: 157-61
31. Ziaee V, Razaei M, Ahmadinejad Z , Shaikh H,Yousefi R,Yarmohammadi L, et al.The changes of metabolic profile and weight during Ramadan fasting. Singapore Med J 2006;45:409-14
32. Maislos M, Khamaysi N, Assali A, AbouRabiah Y, Zvili I, Shany S. Marked increase in plasma high-density-lipoprotein cholesterol after prolonged fasting during Ramadan. Am J Clin Nutr . 1993;57:640-642.
33. Shehab A, Abdulle A, El Issa A, Al Suwaidi J, Nagelkerke N. Favorable changes in lipid profile: the effects of fasting after ramadan. PLoS One. 2012;7:e47615.doi: 10.1371/journal.pone.0047615. Epub 2012 Oct 24.
34. Yarahmadi S, Larijani B, Bastanhagh MH, Pajouhi M, Baradar JR, Zahedi F, et al. Metabolic and clinical effects of Ramadan fasting in patients with type II diabetes. J Coll Physicians Sur Pak 2003;13:329-332.
35. Akanji AO, Mojiminiyi OA, Abdella N. Beneficial changes in serum apo A-1 and its ratio to apo B and HDL in stable hyperlipidaemic subjects after Ramadan fasting in Kuwait. Eur J Clin Nutr 2000; 54: 508-513.
36. Al-Arouj M, Bougurra R, Buse J, Hafez S,Hassanein M,Ibrahim, al. Recommendations for management of diabetes during Ramadan. Diabetes Care 2005;28:2305-11.
37. Sheikh A. Pre-Ramadan Counseling. In: zargar AH, Kalra S (eds). Ramadan and Diabetes Care. 1st ed. JAYPEE - The Health Sciences Publisher; 2014.
38. Eckel RH, Jakicic J M, Ard JD, de Jesus JM, Miller NH, Hubbard VS, et al. 2013 AHA/ACC Guideline on Lifestyle Management to Reduce Cardiovascular Risk. In Press. J Am Coll Cardiol 2013;63:2960-84.
39. Nomani MZA. Dietary fat, cholesterol and uric acid levels during Ramadan fasting. International Journal Ramadan Fasting 1997;1:1-6
40. Reid KJ, Baron KG, Zee PC. Meal timing influences daily caloric intake in healthy adults. Nutr Res 2014;34:930-5
41. Shaikh A. Physical activity in Ramadan. In: zargar AH, Kalra S, (eds). Ramadan and Diabetes Care. 1st ed. JAYPEE - The Health Sciences Publisher; 2014.

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