|Year : 2019 | Volume
| Issue : 3 | Page : 63-67
Effect of Ramadan fasting on fatigue, mood, and cognition in old chronic kidney disease Egyptian patients: a pilot study
Moustafa A Mahmoud1, Esraa A Barakat2
1 Department of Internal Medicine (Nephrology unit), Faculty of Medicine, Mansoura University, Mansoura, Egypt
2 Department of Psychiatry, Sherbin General Hospital, Sherbin, Egypt
|Date of Submission||27-Jan-2019|
|Date of Acceptance||09-Jun-2019|
|Date of Web Publication||2-Aug-2019|
MD Moustafa A Mahmoud
Department of Internal Medicine, Faculty of Medicine, Mansoura University, Mansoura, 35516
Source of Support: None, Conflict of Interest: None
Introduction Muslims fast during the whole lunar month of Ramadan from dawn to sunset. Some studies have evaluated the effect of the different patterns of intermittent fasting including Ramadan fasting (RF) on the perception of fatigue, mood, and cognitive functions in healthy individuals and in some patient groups, but the effect of RF on the perception of fatigue, mood, and cognitive functions was not assessed previously in patients with chronic kidney disease (CKD).
Aim This study aimed to evaluate the effect of RF on fatigue, depressed mood, anxiety, and cognition in a cohort of old Egyptian CKD patients who fulfilled fasting during the whole month of Ramadan.
Patients and methods This was an observational pilot study that included 20 CKD patients (eight men and 12 women), mean age 61.9 years, who fasted during the whole lunar month of Ramadan. Fatigue, mood, and cognition were assessed using standardized questionnaires before and after RF. Complete blood count, serum creatinine, estimated glomerular filtration rate, serum albumin, body weight, BMI, and body composition assessed by bioimpedance analysis were determined within a week before and within a week after RF.
Results RF was associated with significant worsening of fatigue (P=0.001), depressed mood (P<0.000), and cognition (P<0.000), whereas anxiety was not significantly changed (P=0.163). RF was not associated with a significant change in creatinine (P=0.132), estimated glomerular filtration rate (P=0.097), or albumin (P=0.352). RF was not associated with a significant change in body weight (P=0.445) BMI (P=0.168), body fat (P=0.979), muscle mass (P=0.662), or body water (P=0.815).
Conclusion RF is associated with significant worsening of fatigue, mood, and cognition in old CKD patients. RF had no significant effect on renal function tests or body composition in these patients.
Keywords: anxiety, chronic kidney disease, cognition and bioimpedance analysis, depression, fatigue, Ramadan fasting
|How to cite this article:|
Mahmoud MA, Barakat EA. Effect of Ramadan fasting on fatigue, mood, and cognition in old chronic kidney disease Egyptian patients: a pilot study. J Egypt Soc Nephrol Transplant 2019;19:63-7
|How to cite this URL:|
Mahmoud MA, Barakat EA. Effect of Ramadan fasting on fatigue, mood, and cognition in old chronic kidney disease Egyptian patients: a pilot study. J Egypt Soc Nephrol Transplant [serial online] 2019 [cited 2020 May 28];19:63-7. Available from: http://www.jesnt.eg.net/text.asp?2019/19/3/63/263901
| Introduction|| |
Chronic kidney disease (CKD) is defined as abnormalities of the kidney structure or function, present for more than 3 months, with implications for health . Poor outcomes in CKD patients are commonly related to comorbidities that may be a cause of CKD such as diabetes mellitus and hypertension or a common association as heart failure and coronary artery diseases. Less is known about the burden of mental health conditions on CKD outcomes . There is now solid evidence linking CKD with impairments in emotional function, quality of life, cognitive functions, and fatigue .
In terms of the emotional status, both depression and anxiety are common in CKD patients. Although the actual prevalence of depressive symptoms among CKD patients is usually underestimated, it has been reported to be nearly three times higher than that in the general population . High depressive symptoms in patients with CKD were associated with a more rapid decrease in kidney function, increased hospital admissions, and more comorbidities . Anxiety is also common among CKD patients. In a cross-sectional study, Lee et al.  reported that the prevalence of anxiety was 24.8, 29.9, and 34.3% in CKD stages 3, 4, and 5, respectively, whereas the prevalence of anxiety in the general population was estimated to be ∼18% .
Patients with CKD also have a higher prevalence of cognitive dysfunction even among patients without overt dementia . The REGARDS (Reasons for Geographic and Racial Differences in Stroke) Study involving 23 405 participants showed that lower levels of kidney function assessed by the estimated glomerular filtration rate (eGFR) are associated with an increased prevalence of cognitive impairment . Another study on CKD patients aged 55 years or older yielded similar results .
Impaired physical functioning measured by different tests and self-reported fatigue are very common in CKD patients . Fatigue was also more common in old CKD patients compared with age-matched individuals without CKD .
Muslims fast during the holy month of Ramadan. Fasting includes abstinence from food, water, and sex from sunrise to sunset for 30 consecutive days. The duration of the fasting ranges from 10 to 18 h per day according to the geographic location and the season. Although individuals with chronic illnesses are exempted from fasting according to Islamic beliefs, many patients insist on fasting against medical advice .
Prolonged fasting, and changes in lifestyle and eating habits during Ramadan may cause complications such as dehydration, decreased blood pressure, and hyper viscosity predisposing to further kidney injury and increased cardiovascular risk in patients with CKD .
However, fasting in CKD patients is associated with improved lipid profile, thus decreasing cardiovascular risk . To date, there are no guidelines or standardized protocols on this topic.
Although many studies have evaluated the effect of Ramadan fasting (RF) on progression of CKD, chronic inflammation, immunity, body composition, and cardiovascular risk in patients with CKD, no studies have evaluated the effect of RF on mental health in these patients. This study aimed to evaluate the effect of RF on the perception of fatigue, mood, and cognitive function in CKD patients.
| Patients and methods|| |
This was a prospective self-controlled observational pilot study that included CKD patients older than 50 years who were selected during regular follow-up in the nephrology outpatient clinic. Only patients who intended to fast during the lunar month of Ramadan and did not have uncontrolled diabetes mellitus, significant cardiovascular, liver, and cerebrovascular disease, or dementia were selected. The study included 20 patients (eight men and 12 women). An informed written consent was signed by all participants and the study protocol was approved by the Institutional Research Board (IRB) of the Faculty of Medicine, Mansoura University, and had the code number: R.18.05.184-2018/05/06.
All patients completed 30 days of fasting from dawn to sunset starting from 17 of May 2018 to 15 of June 2018. The mean daily duration of fasting was 14.5 h. Patients were evaluated a week before and a week after RF. Evaluation involved the following:
- Thorough clinical assessment including body weight, height, and BMI calculation.
- Assessment of body composition by electrical bioimpedance analysis using the segmental body composition monitor Tanita DC 430 PMA. The instrument estimated body fat%, body water%, muscle mass, and bone mass.
- Assessment of fatigue using the Samn–Perelli seven-point scale .
- Depression was assessed using the Beck Depression Inventory (BDI) .
- Anxiety was assessed using the State-Trait Anxiety Inventory (STAI) .
- Cognition was assessed by Mini Mental State Examination (MMSE) .
- Laboratory investigations including complete blood count, serum albumin, and serum creatinine. The eGFR was calculated using the CKD epidemiology collaboration equation .
The collected data were analyzed using the Statistical Package for Social Sciences (SPSS) software version 17 (SPSS Inc., Chicago, Illinois, USA). Nominal variables were expressed as number and percentage. Ordinal variables (scales) were expressed as median and range. Ordinal variables were compared before and after RF using the Wilcoxon test. Quantitative variables were assessed for skewness and kurtosis using the Shapiro–Wilk test. All quantitative variables were normally distributed and were expressed as mean±SD. Quantitative variables were compared before and after RF using a paired-samples t test.
| Results|| |
This study involved 20 patients with a mean age of 61.9±5.24 years, eight men and 12 women. All patients were CKD stage III b or stage IV. There was no significant change in body weight, BMI, or body composition assessed by bioimpedance analysis after RF as shown in [Table 1].
There was no significant change in renal function tests, albumin, hemoglobin, or white blood cell count after RF, whereas the platelet count increased significantly after RF as shown in [Table 2].
Self-reported fatigue assessed by seven-point scale increased significantly after RF (P=0.001). The depression score assessed by BDI increased significantly after RF (P<0.000), whereas anxiety assessed by STAI increased only slightly (P=0.163). Cognitive functions assessed by MMSE deteriorated significantly after RF (P<0.000) as shown in [Table 3].
| Discussion|| |
RF is one of the five pillars of Islam. Sick people are exempted from fasting. We routinely advise patients with advanced CKD against fasting. Also, CKD patients with uncontrolled diabetes mellitus, liver cirrhosis, coronary artery disease, and heart failure though advised not to fast, many CKD patients including old patients insist to fulfill this religious duty.
Although this study was carried out in the summer in an area with hot weather, all patients could complete 30 days of fasting. Serum creatinine and eGFR did not change significantly after RF. Many other studies have evaluated the effect of RF on renal function in patients with CKD. Most studies showed the safety of RF in these patients. A meta-analysis including six studies three of which were conducted in hot seasons has confirmed this conclusion . Another study compared a group of CKD patients who fasted during Ramadan to a control group of CKD patients who did not fast and reported similar results . Few studies have shown worsening renal functions with RF. An observational trial including 65 participants showed worsening of renal function with RF in 33% of patients. Interestingly, this study identified young age as a risk factor for worsening renal function with RF in these patients . This may be related to more physical activity associated with more dehydration in this age group. Variable results on the effect of RF on renal functions may be related to many factors including weather, fasting duration, age, comorbidities, degree of physical activity, type of drugs, and social and nutritional habits.
Although many studies have evaluated the effect of RF on the physical health of CKD patients, no studies have previously evaluated the effect of RF on the mental health of these patients. In our study, self-reported fatigue, assessed using a simple seven-point scale developed by Samn and Perelli, showed a significant increase in the perception of fatigue after RF. Depression assessed by BDI increased significantly after RF. Anxiety assessed by STAI also increased, but the change was not statistically significant. Cognitive functions assessed by MMSE deteriorated significantly after RF. These changes cannot be explained by deterioration in renal functions, dehydration, or decreased caloric intake because serum creatinine, eGFR, body weight, BMI, total body water, and serum albumin were not affected by RF.
To our knowledge, this was the first study to evaluate the effect of RF on mental health in CKD patients, whereas the effect of RF on mood, cognition, and physical performance was assessed previously in healthy individuals, athletes, selected occupations and selected diseases with variable results. RF did not affect mood and fatigue in healthy young individuals . Nurses showed a significant increase in the fatigue level after RF , whereas stress and depression improved significantly with RF in another study . Patients with ulcerative colitis reported improved depression and anxiety with RF . Cognitive functions were also not affected by RF in healthy individuals ,,.
| Conclusion|| |
Although renal function tests were not affected by RF, fatigue, depression, and cognitive functions had deteriorated significantly after RF in old CKD patients. This effect was not related to changes in renal function, nutritional, or hydration status.
Study limitations and recommendations
Our study did not offer an explanation for the effect of RF on mental health. The small number and narrow age range were major limitations of this study. Further evaluation of the effect of RF on fatigue, mood, and cognition on a larger number of patients with a wider age range is needed. The effects of comorbidities, ongoing drug therapy, and type of physical activity should be considered. Evaluation of the effect of RF in different geographic areas with different weather conditions, ethnic groups, religious, social, and nutritional habits is needed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Kidney Disease: Improving Global Outcomes (KDIGO) CKD Work Group. KDIGO 2012 clinical practice guideline for the evaluation and management of chronic kidney disease. Kidney Int Suppl 2013; 3:19.
Tonelli M, Wiebe N, Guthrie B, James MT, Quan H, Fortin M et al.
Comorbidity as a driver of adverse outcomes in people with chronic kidney disease. Kidney Int 2015; 88:859–866.
Kittiskulnam P, Sheshadri A, Johansen KL. Consequences of CKD on functioning. Semin Nephrol 2016; 36:305–318.
Kessler RC, Berglund P, Demler O, Jin R, Koretz D, Merikangas KR et al.
The epidemiology of major depressive disorder: results from the National Comorbidity Survey Replication (NCS-R). Jama 2003; 289:3095–3105.
Tsai YC, Chiu YW, Hung CC, Hwang SJ, Tsai JC, Wang SL et al.
Association of symptoms of depression with progression of CKD. Am J Kidney Dis 2012; 60:54–61.
Lee YJ, Kim MS, Cho S, Kim SR. Association of depression and anxiety with reduced quality of life in patients with predialysis chronic kidney disease. Int J Clin Pract 2013; 67:363–368.
Kessler RC, Chiu WT, Demler O, Merikangas KR, Walters EE. Prevalence, severity, and comorbidity of 12-month DSM-IV disorders in the National Comorbidity Survey Replication. Arch Gen Psychiatry 2005; 62:617–627.
Ito H, Antoku S, Mori T, Nakagawa Y, Mizoguchi K, Matsumoto S et al.
Association between chronic kidney disease and the cognitive function in subjects without overt dementia. Clin Nephrol 2017; 89: 330–335.
Kurella Tamura M, Wadley V, Yaffe K et al.
Kidney function and cognitive impairment in US adults: the Reasons for Geographic and Racial Differences in Stroke (REGARDS) Study. Am J Kidney Dis 2008; 52:227–234.
Yaffe K, Ackerson L, Kurella Tamura M, Le Blanc P, Kusek JW, Sehgal AR et al.
Chronic kidney disease and cognitive function in older adults: findings from the chronic renal insufficiency cohort cognitive study. J Am Geriatr Soc. 2010; 58:338–345.
Joshwa B, Campbell ML. Fatigue in patients with chronic kidney disease: evidence and measures. Nephrol Nurs J 2017; 44:337–343.
Bowling CB, Sawyer P, Campbell RC, Ahmed A, Allman RM. Impact of chronic kidney disease on activities of daily living in community-dwelling older adults. J Gerontol A Biol Sci Med Sci 2011; 66:689–694.
Sahin SB, Ayaz T, Ozyurt N, Ilkkilic K, Kirvar A, Sezgin H. The impact of fasting during Ramadan on the glycemic control of patients with type 2 diabetes mellitus. Exp Clin Endocrinol Diabetes 2013; 121:531–534.
Aktürk IF, Bıyık I, Koşaş C, Yal.ın AA, Ertürk M, Uzun F. Effects of ramadan fasting on blood pressure control, lipid profile, brain batriuretic peptide, renal functions and electrolyte levels in hypertensive patients taking combination therapy. Nobel Med 2013; 9:43–46.
Bernieh B, Al Hakim MR, Boobes Y, Abu Zidan FM. Fasting Ramadan in chronic kidney disease patients: clinical and biochemical effects. Saudi J Kidney Dis Transpl 2010; 21:898–902.
Samn S, Perelli L. Estimating aircrew fatigue: A technique with implications to airlift operations Technical Report No SAM-TR-82-21. Brooks AFB, TX: USAF School of Aerospace Medicine; 1982. 1–26.
Beck AT, Ward CH, Mendelson M, Mock J, Erbaugh J. An inventory for measuring depression. Arch Gen Psychiatry. 1961; 4:561–571.
Spielberger CD, Gorsuch RL, Lushene R, Vagg PR, Jacobs GA. Manual for the State Trait Anxiety Inventory (STAI). Palo Alto, CA: Consulting Psychologists Press; 1983.
Folstein MF, Folstein SE, McHugh PR. ‘Mini-mental state’ a practical method for grading the cognitive state of patients for the clinician. J Psychiatr Res 1975; 12:189–198.
Levey AS, Stevens LA, Schmid CH. A new equation to estimate glomerular filtration rate. Ann Intern Med 2009; 150:604–612.
Bragazzi NL. Ramadan fasting and chronic kidney disease: does estimated glomerular filtration rate change after and before Ramadan?Insights from a mini meta-analysis. Int J Nephrol Renovasc Dis 2015; 8:53–57.
Hassan S, Hassan F, Abbas N, Hassan K, Khatib N, Edgim R et al.
Does Ramadan fasting affect hydration status and kidney function in ckd patients? Ann Nutr Metab 2018; 72:241–247.
Bakhit AA, Kurdi AM, Wadera JJ, Alsuwaida AO. Effects of Ramadan fasting on moderate to severe chronic kidney disease.A prospective observational study. Saudi Med J 2017; 38:48–52.
Nugraha B, Ghashang SK, Hamdan I, Gutenbrunner C. Effect of Ramadan fasting on fatigue, mood, sleepiness, and health-related quality of life of healthy young men in summer time in Germany: A prospective controlled study. Appetite 2017; 111:38–45.
Ovayolu Ö, Ovayolu N, Taşan E. Does Ramadan fasting affect fatigue in nurses? Holist Nurs Pract 2016; 30:222–226.
Koushali AN, Hajiamini Z, Ebadi A, Bayat N, Khamseh F. Effect of Ramadan fasting on emotional reactions in nurses. Iran J Nurs Midwifery Res 2013; 18:232–236.
Tavakkoli H, Haghdani S, Emami MH, Adilipour H, Tavakkoli M, Tavakkoli M. Ramadan fasting and inflammatory bowel disease. Indian J Gastroenterol 2008; 27:239–241.
] [Full text]
Ghayour Najafabadi M, Rahbar Nikoukar L, Memari A, Ekhtiari H, Beygi S. Does Ramadan fasting adversely affect cognitive function in young females? Scientifica (Cairo) 2015; 2015:432428.
Chamari K, Briki W, Farooq A, Patrick T, Belfekih T, Herrera CP. Impact of Ramadan intermittent fasting on cognitive function in trained cyclists: a pilot study. Biol Sport 2016; 33:49–56.
Harder-Lauridsen NM, Rosenberg A, Benatti FB, Damm JA, Thomsen C, Mortensen EL et al.
Ramadan model of intermittent fasting for 28 d had no major effect on body composition, glucose metabolism, or cognitive functions in healthy lean men. Nutrition 2017; 37:92–103.
[Table 1], [Table 2], [Table 3]