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Ramadan daily intermittent fasting reduces
objectively assessed habitual physical activity
among adults
Abdualziz Farooq ( mohammed.farooq@aspetar.com )
Aspetar Orthopaedic and Sports Medicine Hospital
Karim Chamari
Aspetar Orthopaedic and Sports Medicine Hospital
Suzan Sayegh
Aspetar Orthopaedic and Sports Medicine Hospital
Maha El Akoum
World Innovation Summit for Health (WISH)
Abdulla Saeed Al-Mohannadi
World Innovation Summit for Health (WISH)
Research Article
Keywords: Ramadan fasting, physical activity, daily intermittent fasting, pedometer
Posted Date: April 15th, 2021
DOI: https://doi.org/10.21203/rs.3.rs-385280/v1
License: This work is licensed under a Creative Commons Attribution 4.0 International License.
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Abstract
Background: Muslims around the world practice intermittent fasting during the month of Ramadan once
each year. We hypothesized that daily physical activity could be impacted due to the inability to refuel
and rehydrate in the fasting state. Therefore, this study aimed to determine the effects of Ramadan
fasting on daily physical activity in the adult community of Qatar.
Methods: A cohort study design among adults registered with national physical activity community
program. Data from a pedometer-based community program was used to extract 3 months of daily step
counts before, during, and after Ramadan for the past ve years (2015-2019). A survey was conducted
among participants to determine fasting practice and other health and environmental factors.
Results: A total of 209 participants completed the survey and provided valid data on physical activity.
During Ramadan, the average steps per day decreased signicantly (-385± SE 158) among participants
who fasted (n=155) p=0.046 and increased (+731.4± SE 247) for the non- fasting participants (n=48)
p=0.010.
Conclusion: Fasting during Ramadan impacts the daily physical activity behavior among Muslims.
Interventions should focus on creating awareness of the importance of maintenance of adequate
physical activity for adults fasting during Ramadan.
Article Summary
Participants performing religious daily intermittent fasting in Ramadan reduce their daily habitual
physical activity.
Physical activity levels remain low even one month following the month of Ramadan.
Non fasting participants on other hand increase physical activity during Ramadan.
Introduction
Fasting during the holy month of Ramadan is considered as one of the ve fundamental pillars of Islam,
thus, an obligatory religious duty for all healthy Muslim adults. Ramadan is based on a lunar calendar
where the duration varies between 29 and 30 days. Each year, this month shifts forward around 10 days
in a Gregorian calendar. During this month, Muslims refrain from eating and drinking during daylight
hours. The fast begins early morning after
Suhoor
(meal taken just before dawn) and ends with
Iftar
(meal taken at sunset)[1]. The duration between
Suhoor
and
Iftar
is the duration of fasting and this can
vary based on geographical location and season [2]. For instance, it averages from 14 to 15 hours in the
Middle East and up to 20 or 21 hours at higher latitudes (e.g. Scandinavian countries) during summer
This variability in fasting time alters the schedule of other daily living activities that have an impact on
human health such as sleep and exercise [3].
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Ramadan fasting has captured public attention in recent years due to the recent rise in popularity of daily
intermittent fasting as means to improve health and reduce weight [4]. Ramadan fasting has been well
documented in scientic literature [5-8] where scientists have investigated the effects of fasting during
Ramadan with respect to its impact on an individual’s biochemistry (e.g., glucose utilization) [9-12], blood
pressure [13], metabolism [14], bodyweight [11, 14], sleep [3, 9, 15] and general health [9, 16]. Much of
these existing research considered the challenges of chronic illnesses such as diabetes and hypertension
on fasting Muslims or focused on athlete’s performance during Ramadan Fasting [17, 18]. Although,
there is a strong dose-response relationship with number of step count per day and reduced risk of all-
cause mortality [19], the effect of Ramadan fasting on community daily physical activity in the literature
is scarce [20, 21].
Some of the few published studies [12, 21] that have addressed the impact of Ramadan on physical
activity have used qualitative methods rather than quantitative methods to assess physical activity .
Insucient physical activity is one of the leading risk factors for diabetes, cardiovascular disorders, and
their associated mortality [22, 23]. Research indicates that an optimal level / increased physical activity
has a benecial effect both on the disease by reducing blood glucose levels and blood pressure as well
as on disease prevention [23, 24]. Moreover, based on international recommendations, an individual
should engage in at least 60 minutes of moderate to vigorous intensity physical activity daily for
optimum health [23]. And at least 8000 steps/day can be equated to 20 min of moderate activity [25].
The intermittent fasting schedule during Ramadan poses a challenge in meeting this objective because
of the lack of immediate external energy supply in a fasting state, inability to refuel, inability to hydrate
while fasting [26], and disturbances in the sleep-wake cycles that become shifted/disturbed (e.g., taking
daytime naps to make up for sleep loss during the night) [2]. Individuals can utilize non-daylight hours for
physical activity but the hours after sundown often involve a busy schedule in which all day-to-day
activities are planned. In addition, an increased amount of time is spent during the evening performing
religious prayers [22].
The physical activity of the non-Muslims living in a Muslim country may also be impacted during the
month Ramadan, even though they do not fast. Indeed, during Ramadan in some Muslim-majority
countries, working hours are shortened (e.g., ≤6 hours per workday), which may also impact a non-
faster’s daily routine (e.g., having more time to do activities that the individual would ordinarily not have
time to do).
The main hypothesis of this study is that physical activity during Ramadan will be affected and will
impact both fasting and non-fasting individuals living in a Muslim-majority country because of working
conditions and/or cultural inuences. Therefore, the aim of the current study was to use a quantitative
method—pedometry—to determine how physical activity is affected by daily intermittent fasting during
the month of Ramadan.
Methods
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Study design and population
This is a community-based cohort study which aimed to explore the effect of Ramadan fasting on
physical activity assessed by daily steps count per day in Qatar. A total of 209 participants took part in
this study (adults aged 18 and above) registered members of the Step into Health (SIH) program during a
period of 5 years (2015-2019). Details and program description have been published elsewhere [27]
.
Participants were excluded if they refused to participate, had invalid physical activity data or in case of
incomplete questionnaire (
described below
).
Settings:
This study was conducted in Qatar which has a population of estimated 2.8 million (as of 2019). The
pedometry data was collected to represent the Ramadan months for the past 5 years (2015-2019) where
Ramadan dates were: June 17 to July 16, June 6 to July 5, May 26 to June 24, May 16 to June 14 and
May 5 to June 4, respectively. The usual temperature ranged from 27 degrees Celsius to 41 degrees over
the study periods [28]. The usual fasting hours in Qatar lasts around ~14-15 hours each day.
Data collection
Basic demographic information of the study population was extracted from the program database,
including age, gender, and nationality. Body Mass Index (BMI) was calculated based on self-reported
body weight and height. According to the WHO classication, normal weight was dened as BMI <25,
overweight as BMI 25–<30, and obese as BMI ≥30 [29]. Other information, such as education, marital
status, and religion were gathered later through a questionnaire (
described below
).
Questionnaire
In addition to basic demographic information, the questionnaire included a series of questions related to
health status such as smoking habits, diagnosis of any chronic disease (i.e. hypertension, diabetes
mellitus, heart disease, allergy, kidney disease, etc.). It also included Ramadan-related questions such as
the fasting duration throughout the period 2015-2019, exercise habits, preferred time for exercise, in
addition to the inuence of Ramadan on levels of physical activity and weight (body mass in kg) change.
Participants were also asked about their preferred location for physical activity. The questionnaire was
developed in English and was then translated into Arabic. The Arabic version of the questionnaire was
back-translated into English to ensure the wording used in English corresponded with cultural context in
Arabic and standards used within this population. The questionnaire was anonymous. Participants
provided their identication details such as email address and national ID, to enable use to link their
responses with the physical activity pedometry data in the SIH system. In order to increase response rate,
we had announced that 2 participants who completed the survey will be randomly selected to receive a
lucky draw prize (137$ coupon- Winners were one man and one woman).
Physical activity measurement
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Step count was extracted from the SIH web database for three consecutive months (before, during and
after the month of Ramadan for each of the Ramadan periods during the past 5 years (2015-2019). Daily
habitual physical activity was assessed through Omron HJ-324U pedometer (Omron Healthcare Co., Ltd.,
Kyoto, Japan) which was used to record the total step count each day. These pedometers were previously
validated, and have an absolute percent error of < 3.0% and a coecient of variation of < 2.1% [30, 31].
Individuals have been uploading their pedometer recordings through an online platform
(www.stepintohealth.qa). Daily step counts <500 and above 50,000 per day were considered invalid [28],
thus, excluded from analyses . Aerobic step counts are computed separately by the pedometer when a
person successively walks >60 steps/min for a duration of at least 10 minutes, as per the denition [28].
To be eligible for inclusion, participant must have provided ≥4 days of valid pedometer data during a
week (at least 3 weekdays and 1 weekend day) [32].
Study size: All participants with valid data on pedometer for a given year, before during and after
Ramadan were contacted by email. For a ve-year period, eligible number of participants with valid
pedometer data was 1306 participants Of all the participants who were invited, only 209 provided
completed questionnaires and were included in the analysis. Participants were divided into two groups
participants who fasted all or most of the days in Ramadan against participants who rarely or did not
fast (see questionnaire).
Statistical data analysis:
All data was coded and analyzed using IBM SPSS Statistics for Windows, Version 21.0. Armonk, NY: IBM
Corp. All data was mostly categorical data and hence presented as counts and percentages. Steps count
data was continuous and it was analyzed using linear mixed models to describe time changes in physical
activity. Socio-demographic factors and fasting status were considered as xed factors separately and
participant ID was the clustering random variable using unstructured covariance structure for time
(before, during and after Ramadan) as repeated measurement. Estimated marginal means ± standard
error was presented and post hoc pairwise differences were reported after Bonferroni adjustment. P-value
<0.05 was considered cut-off for statistical signicance.
Results
Study participants
Table 1 presents the patients’ demographic information of the 209 participants. Most participants were
male (75.0%), had a university education (86.6%), were married (88.0%), were non-smokers (80.4%),
practiced Islam (74.2%), and healthy (did not have a chronic condition such as high blood pressure,
diabetes mellitus, and heart or kidney disease- 71.3%). When asked about preferred location for physical
activity, the top responses from participants were parks (57.9%), walking trails (45.5%), neighborhood
(33.5%).
