Will Fasting Repair Lung Tissue

Am J Mens Health. 2018 Mar; 12(2): 359–369.

The Effects of Ramadan Intermittent Fasting (RIF) on Spirometric Data of Stable COPD Patients: A Pilot Study

Hajer Zouari, MD,^{1, †} Imed Latiri, PhD,^{1, †} Mohamed Mahjoub, MD,ⁱⁱ Mohamed Boussarsar, MD,^{3, four} Mohamed Benzarti, MD,^v Ahmed Abdelghani, MD,^{iv, 5} and Helmi Ben Saad, Dr., PhD^{1, 4, vi}

Hajer Zouari

¹Physiology Laboratory, Faculty of Medicine of Sousse, University of Sousse, Tunisia

Imed Latiri

^anePhysiology Laboratory, Faculty of Medicine of Sousse, Academy of Sousse, Tunisia

Mohamed Mahjoub

²Department of Hospital Hygiene, Farhat HACHED Academy Hospital in Sousse, Tunisia

Mohamed Boussarsar

^threeMedical Intensive Intendance Unit, Farhat HACHED University Infirmary in Sousse, Tunisia

^ivResearch Laboratory LR14ES05: interaction of the cardiorespiratory system, Kinesthesia of Medicine of Sousse, University of Sousse, Tunisia

Mohamed Benzarti

^vPulmonary Department, Farhat HACHED University Infirmary in Sousse, Tunisia

Ahmed Abdelghani

⁴Research Laboratory LR14ES05: interaction of the cardiorespiratory system, Faculty of Medicine of Sousse, University of Sousse, Tunisia

^fivePulmonary Section, Farhat HACHED University Hospital in Sousse, Tunisia

Helmi Ben Saad

^anePhysiology Laboratory, Faculty of Medicine of Sousse, University of Sousse, Tunisia

^fourResearch Laboratory LR14ES05: interaction of the cardiorespiratory system, Faculty of Medicine of Sousse, University of Sousse, Tunisia

⁶Physiology Department and Functional Exploration, Farhat HACHED Academy Hospital in Sousse, Tunisia

Received 2017 Jun 4; Revised 2017 Aug 5; Accepted 2017 Aug sixteen.

Abstract

No previous study has raised the effects of RIF on lung function data of chronic obstructive pulmonary affliction (COPD) patients. The objective of the present written report was to assess the effects of RIF on spirometric information measured in male patients with a stable COPD. Sixteen patients with stable COPD (mean ± SD of age: 64 ± 7 years) who fasted during Ramadan volunteered to the study. Three sessions (Before-R, Terminate-R, and After-R) were selected for spirometry tests that were consistently performed 2.five–4.v hr before fasting suspension. Assessment sessions comprised: forced vital capacity (FVC), 1st s forced expiratory volume (FEV_ane), FEV₁/FVC, pinnacle expiratory flow (PEF), maximal mid-expiratory flow (MMEF), and forced expiratory menstruum charge per unit at the x% of FVC to be exhaled (FEFx%). A reversibility test was performed only during the Before-Ramadan session. Spirometric data were expressed in percentages of local reference values. Findings were analyzed by applying repeated measures analysis of variance. The mean ± SD of the postbronchodilator FEV₁/FVC ratio and the FEV_ane were, respectively, 0.52 ± 0.14 and 48 ± xix%. The hateful ± SD of FEV₁ (Before-R: 47 ± 19, End-R: 45 ± eighteen, After-R: 44 ± nineteen%), FVC (Before-R: 73 ± xviii, Finish-R: 71 ± 16, Subsequently-R: 69 ± 17%), FEV₁/FVC (Before-R: 67 ± 16, End-R: 66 ± 16, After-R: 65 ± 16%), PEF (Before-R: 46 ± xix, Terminate-R: 47 ± 22, Later-R: 45 ± 21%), MMEF (Earlier-R: 19 ± 10, End-R: 18 ± viii, Later-R: xviii ± 9%), FEF_25% (Before-R: 16 ± 6, Finish-R: 16 ± 5, After-R: 15 ± v%), FEF_50% (Before-R: 21 ± fourteen, End-R: 20 ± 12, Later on-R: xx ± 12%) and FEF_75% (Before-R: 27 ± 19, End-R: 27 ± 19, After-R: 27 ± 19%) were not significantly influenced by RIF. RIF did not bring about whatsoever pregnant changes in the spirometric data of stable COPD male person patients fasting the 2016 holy calendar month of Ramadan.

Keywords: fasting, summertime, chronic obstructive pulmonary disease, respiratory disease, lung role data

Ramadan intermittent fasting (RIF) consists of alternating fasting and feasting periods (Bragazzi, 2015a). Information technology is non merely the abstinence (from dawn to sunset) from all types of liquid and solid nutrient intake, merely likewise from smoking, medication, and sexual intercourse (Bragazzi, 2015a). This brake besides includes medications given via oral and parenteral route, but not drugs used via inhalation route (Official Web site of The Presidency of Religious Diplomacy of the Commonwealth of Turkey, n.d.). The fasting is broken, taking two traditional meals, pre-dawn (suhoor) and after-sunset (iftar) meals. Ramadan, the ninth month of the Muslim lunar agenda, which retreats 11 agenda days each year, is detail for the long mean of abstinence from food (Bragazzi, 2015a). The RIF duration depends on the geographical area, season and country, finish of spring, kickoff of summer, the tropics and temperate locations being longer (Fenneni et al., 2014; Haouari et al., 2008). The fasting hateful duration is usually 12–14 hour but can last up to eighteen or even 22 hr in the summer in extreme latitude regions (Fenneni et al., 2014; Haouari et al., 2008).

Fasting is non compulsory for pre-pubescent children, frail elderly, travelers, menstruating, pregnant and breastfeeding women (Athar, 1990). Patients are besides exempted from fasting because of ongoing disease conditions (Athar, 1990). In practice, several patients with chronic conditions (Adeli, Aghaali, & Nasab, 2015; Al-Dubeikil & Abdul-Lateef, 2003; Askari, Alavinezhad, & Boskabady, 2016; Aydin et al., 2014; Babineaux et al., 2015; Bener, Colakoglu, Mobayed, & Sabbah, 2006; Bragazzi, 2015b; Chamsi-Pasha & Chamsi-Pasha, 2016; Erkekol et al., 2006; Herrag, Lahmiti, & Yazidi, 2010; Nematy et al., 2015; Norouzy et al., 2013; Tas et al., 2014) exercise not have these exemptions and prefer fasting (and/or want to fast and/or insist on fasting) during Ramadan. For example, 67% of Muslim asthmatics exercise non consider asthma to be a drawback to fasting, and continue fasting by rearranging their medication times to iftar and suhoor (Erkekol et al., 2006). Almost three% of Muslim patients with lung cancer (Tas et al., 2014) and 93% of Turkish chronic obstructive pulmonary disease (COPD) patients (Aydin et al., 2014) are Ramadan fasters. Although the relationship between religion rituals and health, and particularly the effects of RIF on chronic diseases, has been an interesting issue for physicians nearly for 30 years, this issue was only tackled in a few studies presenting controversial findings (Abdel-aziz & Ibraheem, 2008; Adeli et al., 2015; Askari et al., 2016; Aydin et al., 2014; Bener et al., 2006; Duncan, Husain, Raman, Cheah, & Ch'ng, 1990; Erkekol et al., 2006; Latiri et al., 2017; Moosavi, Kabir, Moghimi, Chehrei, & Rad, 2007; Nematy et al., 2015; Norouzy et al., 2013; Siddiqui, Sabir, & Subhan, 2005; Singha Roy & Bandyopadhyay, 2016; Soori, Mohaghegh, Hajain, & Moraadi, 2016; Subhan, Siddiqui, Khan, & Sabir, 2006). Moreover, the opinions of health-care professionals and scholarly societies, concerning the effects of RIF on wellness, are divided. Some societies, similar the England National Health Service (Data for health-care professionals on fasting and medicines during Ramadan, n.d.), consider that RIF is dangerous for patients with asthma and/or COPD, since they may experience complications. Others, like the international COPD coalition (Role of the International COPD, n.d.), approximate it to be safe and suggest patients to rearrange their medication times to iftar and suhoor and to interruption the fasting during exacerbation. For COPD patients, the contempo international guidelines (Celli et al., 2015; Vogelmeier et al., 2017) suggested orderly use of the symptom-relieving treatment as well every bit the disease-development prevention, such as the monitoring and teaching of patients equally well as the avoidance of chance factors (Askari et al., 2016). Nevertheless, the furnishings of religious beliefs and behaviors oasis't been addressed and no recommendation has been advanced for COPD patients who prefer fasting during Ramadan.

The spirometry test is a useful investigation tool for diagnosing and monitoring a diversity of adults' respiratory diseases (Miller et al., 2005). During the month of Ramadan, spirometric tests go along to be normally performed on patients with COPD who want to fast. The master question remains: how to translate in these patients, whatsoever possible lung function information changes? Are they caused by the likely effects of fasting on the lung or by medication-utilise (in case of improvement) or clinical worsening (in case or deterioration)? Several studies have observed the furnishings of RIF on trunk functions in patients with chronic atmospheric condition (Adeli et al., 2015; Al-Dubeikil & Abdul-Lateef, 2003; Askari et al., 2016; Aydin et al., 2014; Babineaux et al., 2015; Bener et al., 2006; Bragazzi, 2015b; M. Chamsi-Pasha & H. Chamsi-Pasha, 2016; Erkekol et al., 2006; Herrag et al., 2010; Nematy et al., 2015; Norouzy et al., 2013; Tas et al., 2014). Yet, studies examining the RIF effects on lung function data, are scarce, included but healthy adults or asthmatic adult patients and presented some discrepancies in their findings (Abdel-aziz & Ibraheem, 2008; Adeli et al., 2015; Askari et al., 2016; Bener et al., 2006; Duncan et al., 1990; Latiri et al., 2017; Moosavi et al., 2007; Norouzy et al., 2013; Siddiqui et al., 2005; Singha Roy & Bandyopadhyay, 2016; Subhan et al., 2006; Soori et al., 2016). In view of the above considerations, the aim of the present pilot written report was to assess the furnishings of RIF on spirometric data measured in male person patients with a stable COPD. As seen in salubrious Tunisian adults (Latiri et al., 2017), the null hypothesis was that RIF did non bring well-nigh whatever significant changes in the spirometric values of patients with a stable COPD.

Population and Methods

Study Pattern

The present written report was designed as a pilot cross-sectional and experimental study. It was performed at the Farhat HACHED University Infirmary, Sousse (Tunisia). Approval for the report was obtained from the Upstanding Committee of the local Hospital (approval number 2602/2015) and oral consent was obtained from all patients. Participants were informed they were complimentary to leave the study at any fourth dimension. Patients were not charged any fees for the spirometry test.

The study was performed during summer of 2016. During the report, the elapsed time from dawn to dusk was ~16.5 hr during the whole calendar month of Ramadan (June 6 to July five). The ambient temperature and humidity means ± standard divergence (SD) during the l-day study period (June 1 to July 20, 2016) were, respectively, 26.5 ± 2.iv °C and 62.0 ± 7.5%.

Sample Size

The sample size was estimated according to a predictive formula (Kang, Ragan, & Park, 2008) largely detailed in the Appendix. Xv patients were needed.

Report Population

Participants were male COPD patients aged twoscore–lxxx years. They were recruited in two ways. First, the folders and files of COPD patients followed in the above two departments were verified. Second, some patients were directly addressed past two pulmonologists from the Bones Health Group of Sousse. At the showtime of the study, a alphabetic character of information containing details about the report and visit dates was given to the patients. Noninclusion criteria were history of RIF for less than twenty years; narghile-utilize; actual cigarette smoking; smoking history less than ten pack-years; tobacco abeyance less than six months; non-COPD patient; neuromuscular disease; diabetes-mellitus; congestive heart failure; malignancy; vertebral column or thoracic cage abnormalities; oral corticosteroid handling; and lack of cooperation during spirometry examination. Female patients were non included considering Muslim laws forbid them to fast during their menses and because lung role is fairly lowered during menses (Cotes, Chinn, & Reed, 1997). Absence during a testing session was applied as an exclusion criterion. To avoid confounding effects, patients with unstable respiratory state (e.g., respiratory tract infection or COPD exacerbation) within iv weeks prior to the spirometry test were excluded. Patients were instructed to avoid using short-acting bronchodilators 6 to 8 60 minutes prior to the spirometry test. Sampling was made based on a convenience method.

Experimental Design

The experimental design consisted in 3 sessions: 5 days before Ramadan (Before-R: June one–4), 3 days at the end of Ramadan (End-R: June 28–30), and 14 days later on Ramadan (Afterwards-R: July 19–20). During the Before-R session, all patients had to respond a medical questionnaire. Anthropometric data were measured and/or noted and the spirometry examination was performed. During the second and the third sessions, but the anthropometric and the spirometric information were determined.

Collected Data and Practical Definitions

The patients were asked whether they fasted during Ramadan. If the answer was "aye," they were kindly requested to reply further questions related to their socioeconomic and schooling levels, personal medical or surgical histories, chronic medication-utilize, dyspnea, and smoking. The questions were gathered from the American thoracic society medical questionnaire (Ferris, 1978). It was composed of questions asked in local Arabic dialect by the same-trained operator. This non-validated questionnaire was used to assess several field of study characteristics. The patients' history of COPD exacerbation including hospitalizations was recorded. During the 3 sessions, patients were systematically asked virtually the times of their bronchodilator-use, latest meal, and sleep elapsing. Repast-duration [time (hr) betwixt the terminal meal and the spirometry examination] and slumber-duration [time (hr) of sleeping, including dark sleep and naps, before the spirometry test] were noted. Cigarette-smoking (pack-years) and narghile-use were evaluated. Dyspnoea was evaluated co-ordinate to the modified medical inquiry council (mMRC) scale (Fletcher, Elmes, Fairbairn, & Wood, 1959). Two dyspnoea levels were divers (mMRC < 2 and mMRC ≥ 2). COPD exacerbation was divers as an acute worsening of respiratory symptoms that consequence in an additional therapy (Vogelmeier et al., 2017). Two schooling [low (illiterate, chief education) and high (secondary and academy didactics)] and two socioeconomic [low (e.thousand., unskilled worker, jobless) and high (e.k., skilled worker, farmer, manager)] levels were arbitrarily defined. Decimal age (accuracy to 0.1 years) was taken every bit the number of consummate years from birth to the engagement of the report. Peak (±ane cm) and weight (±ane kg) were measured with a mechanical scale (Seca deutschland; Medical Measuring Systems and Scales, seca gmbh & co. kg Hammer Steindamm three-25 22089 Hamburg, Germany). Trunk mass alphabetize (BMI, kg/thousand²) was calculated and the following definitions were adopted (Tsai & Wadden, 2013): underweight (BMI < xviii.5), normal weight (eighteen.5 to 24.ix), overweight (25.0 to 29.9), and obesity (BMI ≥ 30.0).

Spirometry Measurements, COPD Diagnosis and Classification

All spirometric tests were performed at the same time of the day (between 15h00 and 17h00), approximately 279 to 159 min before iftar (mean fasting hours = 16:59 hr). Spirometry was carried out in a standing position. All tests were performed by 1 qualified person (IL in the authors listing) and i portable spirometer (SpirobankG MIR via del Maggiolino 12500155 Roma, Italy) was used. The turbine of the spirometer was calibrated daily with a 3-L syringe. Spirometry was performed co-ordinate to international guidelines (Miller et al., 2005). The spirometric data [forced vital chapters (FVC, 50); 1st s forced expiratory book (FEV_i, L); forced expiratory catamenia when x% of FVC has been exhaled (FEF_10%; 50/south), maximal mid-expiratory flow (MMEF, L/s), peak expiratory catamenia (PEF, L/south), and FEV₁/FVC ratio (absolute value)] were expressed in absolute values at "body temperature, barometric pressure saturated with water vapor" (Miller et al., 2005). The measured spirometric data were as well expressed as percentages of predicted local reference values (Ben Saad et al., 2013). The FVC maneuver was previously described (Latiri et al., 2017). The reversibility test, largely described elsewhere (Ben Saad, Prefaut, Tabka, Zbidi, & Hayot, 2008), was performed only during the Before-R session.

COPD diagnosis was retained in front of a postbronchodilator FEV_one/FVC ratio <0.70 (Celli et al., 2015; Vogelmeier et al., 2017). The severity of airflow limitation, based on the postbronchodilator FEV₁, was classified equally follows: mild (FEV₁ ≥80%); moderate (50% ≤ FEV_i < fourscore%); severe (xxx% ≤ FEV₁ < 50%), and very astringent (FEV₁ <xxx%) (Celli et al., 2015; Vogelmeier et al., 2017). The refined "ABCD" assessment tool derived from the patients' symptoms [i.e., dyspnea (Fletcher et al., 1959)] and their exacerbation history (including prior hospitalizations) was practical (Vogelmeier et al., 2017), and four groups (A, B, C, and D) were categorized.

Statistical Analysis

The analysis of variable distribution was performed using the Kolmogorov–Smirnov test. When the distribution was normal and variances were equal, the results were expressed as mean ± SD (95% confidence interval). Otherwise, the results were expressed past their medians (lower-upper quartiles). Qualitative data were expressed by relative frequency. Comparisons of the anthropometric and the spirometric data, slumber-, and meal-durations and fourth dimension of terminal-employ of bronchodilator were made between the three sessions (Earlier-R, End-R, and After-R). The results were obtained past applying repeated measures assay of variance. When appropriate, significant differences between ways were tested using the Tukey post hoc test. Analyses were carried out using Statistica software (Statistica Kernel version 6; StatSoft, Paris, France). Significance was set up at the 0.05 level.

Results

Among the 25 examined patients, only 16 stable COPD patients completed the iii sessions. The reasons for dropout were postbronchodilator FEV₁/FVC > 0.70 (n = one) and absence during the second (n = 4) or the third (n = 4) sessions.

Viii and ten patients had, respectively, low socioeconomic and depression schooling levels. The median (lower-upper quartiles) of the patients Ramadan experience was 42 years (xl–46). The hateful ± SD (95% confidence interval) of their tobacco history was 36 ± 27 (22–50) pack-years. The median (lower-upper quartiles) of their smoking cessation duration was v.0 years (3.0–15.5). Just one COPD patient wasn't under respiratory handling. Twelve, fourteen, and half dozen patients were treated by bronchodilators, inhaled corticoid and anti-cholinergic, respectively. Seven COPD patients were mMRC ≥ two; four had cardiovascular diseases (two have a stable hypertension, one had an obliterating arteriopathy of the lower limbs and 1 had a dilated cardiomyopathy), two were anemic, one had hypothyroid, and one had dyslipidemia.

The airflow limitation was qualified as "balmy to moderate" and "severe to very severe," respectively, in seven and ix patients. The mean ± SD of the postbronchodilator FEV₁/FVC, FEV₁ and FVC were, respectively, 0.52 ± 0.14%, 48 ± 19%, and 77±xvi%. The refined ABCD assessment tool identified that eight, half-dozen and ii patients belonged, respectively, to groups A, B, and D.

The mean ± SD (95% conviction interval) of age and height were, respectively, 63.63 ± 7.19 (59.eighty to 67.46) years and 172±5 (169 to 174) cm. Twelve, 3, and one patients were, respectively, normal weight, overweight, and obese.

Ambient temperatures and humidity data during the three sessions were presented in Tabular array 1. Ambient temperature was significantly higher during the End-R session compared to the Before-R 1. Humidity was significantly lower during the Afterward-R session compared to the Earlier-R 1.

Table i.

Ambient Temperature, Humidity and some Characteristics of the 16 Stable COPD Patients.

	Sessions			ANOVA
	Earlier-R	Terminate-R	Later-R
Ambient temperature (°C)	24.5 ± ii.1	29.8 ± 0.8	29.0 ± 0.7	.015 * a
Humidity (%)	66.5 ± 5.0	59.7 ± 3.v	54.0 ± two.8	.034 * b
Weight (kg)	66 ± 12 (lx to 73)	66 ± 12 (60 to 72)	66 ± 12 (threescore to 73)	.99
BMI (kg/1000ii)	22.v ± three.ix (20.4 to 24.6)	22.4 ± three.nine (twenty.3 to 24.four)	22.iv ± 3.9 (20.3 to 24.6)	.99
Concluding BD-use (hour)	ix ± v (six to 12)	15 ± 2 (xiv to 16)	9 ± v (6 to 12)	<.001 * a c
Slumber-duration (60 minutes)	7(6–viii)	6(5–eight)	6(6–eight)	.79
Meal-duration (hr)	4 (four–6)	xiv(fourteen–15)	3(3–7)	<.001 * a c

Table 1 reports the patients' characteristics during the three sessions. Its main conclusions were (a) there was no significant effect of RIF on weight or BMI, (b) there was no meaning difference between the iii-session sleep-duration, and (c) there was a pregnant difference betwixt the three-session meal-duration: the End-R meal-elapsing was significantly higher than those of Before and After-R sessions.

Table 2 reports the COPD patient's spirometric data expressed in accented values. RIF had no outcome on their spirometric data. Figures 1 and ​ 2 display the patients' spirometric volumes, ratio and flows expressed equally percentages of predicted values. The hateful ± SD of FEV_one (Before-R: 47 ± 19, Stop-R: 45 ± 18, Afterwards-R: 44 ± 19%), FVC (Before-R: 73 ± 18, Stop-R: 71 ± 16, After-R: 69 ± 17%), FEV₁/FVC (Before-R: 67 ± 16, End-R: 66 ± 16, After-R: 65 ± 16%), PEF (Earlier-R: 46 ± 19, End-R: 47 ± 22, After-R: 45 ± 21%), MMEF (Before-R: 19 ± 10, End-R: 18 ± 8, Afterward-R: 18 ± 9%), FEF_25% (Before-R: 16 ± half-dozen, Stop-R: xvi ± 5, After-R: xv ± 5%), FEF_50% (Earlier-R: 21 ± fourteen, End-R: 20 ± 12, Afterwards-R: 20 ± 12%), and FEF_75% (Before-R: 27 ± 19, Finish-R: 27 ± nineteen, After-R: 27 ± 19%) were non significantly influenced by RIF.

Table 2.

Spirometric Data of the 16 Stable COPD Patients (north = 16).

Parameters	Sessions			ANOVA
	Before-R	End-R	Subsequently-R
FEV1 (50)	1.68 ± 0.70	1.threescore ± 0.65	i.54 ± 0.68	.85
FVC (L)	three.07 ± 0.84	2.98 ± 0.72	two.90 ± 0.76	.81
FEVi/FVC (absolute value)	0.53 ± 0.13	0.52 ± 0.13	0.52 ± 0.13	.97
PEF (Fifty/south)	4.05 ± 1.65	iv.13 ± 1.91	3.95 ± 1.88	.96
MMEF (Fifty/s)	0.91 ± 0.fifty	0.84 ± 0.40	0.83 ± 0.41	.83
FEF25% (L/s)	0.33 ± 0.13	0.32 ± 0.11	0.30 ± 0.11	.68
FEFl% (Fifty/s)	1.04 ± 0.72	0.99 ± 0.62	0.98 ± 0.64	.95
FEF75% (L/southward)	2.21 ± ane.55	ii.21 ± 1.60	2.17 ± ane.59	.98

The effects of Ramadan intermitting fasting on the spirometric volumes and ratio (expressed as percentages of predicted values) of the 16 stable chronic obstructive pulmonary disease patients.

Fig A: 1st due south forced expiratory volume (FEV_ane).

Fig B: forced vital capacity (FVC).

Fig C: FEV₁/FVC ratio.

R: Ramadan.

Information are mean (O) ± 95% confidence interval ().

p: analysis of variance betwixt the three sessions.

The effect of Ramadan intermitting fasting on the spirometric flows (expressed equally percentages of predicted values) of the 16 stable chronic obstructive pulmonary disease patients.

Fig A: peak expiratory flow (PEF).

Fig B: maximal mid expiratory period (MMEF).

Fig C: FEF_25%.

Fig D: FEF_50%.

Fig E: FEF_75%.

FEF_X%: forced expiratory flow when X% of FVC has been exhaled.

R: Ramadan.

Information are mean (O) ± 95% confidence interval ().

p: assay of variance between the three sessions.

Discussion

The chief finding of the present airplane pilot study which addresses the effects of a religious ritual on a group of xvi stable COPD patients identified that RIF did not bring nigh whatsoever significant changes in their spirometric data. The result of RIF on the respiratory system is neither a elementary bookish issue nor is it of awareness only simply in Muslim countries (Bragazzi, 2015a). Information technology has clinically pertinent inferences. In fact, in a globalized culture, doctors may consult Muslim COPD patients who cull fasting during Ramadan (Al Wakeel et al., 2013). Available proof apropos the health benefits of RIF is limited and greatly controversial (Nematy et al., 2015). Although Islam exempts some patients with chronic diseases from fasting, a lot of them obviously fast, and this can cause their clinical condition to deteriorate due to a persistent gap betwixt electric current expert cognition and decisive stiff testify regarding the pathophysiologic and metabolic alterations of fasting (Nematy et al., 2015). To the best of the authors' noesis, no previous study has debated the effects of RIF on lung function data of COPD patients. Some studies have examined the impacts of RIF on respiratory mechanics of both healthy and asthmatic adults (Abdel-aziz & Ibraheem, 2008; Adeli et al., 2015; Askari et al., 2016; Bener et al., 2006; Duncan et al., 1990; Latiri et al., 2017; Moosavi et al., 2007; Norouzy et al., 2013; Siddiqui et al., 2005; Singha Roy & Bandyopadhyay, 2016; Soori et al., 2016; Subhan et al., 2006).

Give-and-take concerning the flavor and the duration of RIF, the timing of spirometric tests, the number of realized sessions and spirometric measurements is available in the Appendix. Only the sample size, patients' characteristics and recruitment methods volition be discussed in the following sentences.

The calculated sample size (due north = 16) is intermediate between those of relative studies including asthmatic patients (Adeli et al., 2015; Askari et al., 2016; Norouzy et al., 2013) [size ranging from xv (Askari et al., 2016) to 30 (Adeli et al., 2015)] or salubrious patients (Abdel-aziz & Ibraheem, 2008; Askari et al., 2016; Duncan et al., 1990; Latiri et al., 2017; Moosavi et al., 2007; Siddiqui et al., 2005; Singha Roy & Bandyopadhyay, 2016; Soori et al., 2016; Subhan et al., 2006) [size ranging from 12 (Soori et al., 2016) to 117 (Moosavi et al., 2007)]. However, due to its airplane pilot nature, the present study findings are preliminary, and should be useful in directing researchers seeking to elucidate the effects of RIF on spirometric information of COPD patients.

A minimal 20-year RIF experience was applied equally an inclusion criterion. It is possible, as seen in studies assessing the effects of RIF on salubrious patients' exercise operation (Chtourou et al., 2012), that the RIF record of the patients could influence their respiratory adaptations (Ben Saad, 2016; Fenneni et al., 2015). This point was not considered in several related studies including salubrious or asthmatic patients (Abdel-aziz & Ibraheem, 2008; Adeli et al., 2015; Askari et al., 2016; Moosavi et al., 2007; Siddiqui et al., 2005; Singha Roy & Bandyopadhyay, 2016; Soori et al., 2016; Subhan et al., 2006; Norouzy et al., 2013). All included COPD patients were ex-smokers. This is a serious indicate to highlight (Ben Saad, 2016), considering smokers compared with ex-smokers, are more than irritable during Ramadan (Kadri et al., 2000) and psychological stress has proved to influence pulmonary role (Kang & Fox, 2000). This data was neglected in some relative studies (Adeli et al., 2015; Duncan et al., 1990; Norouzy et al., 2013; Siddiqui et al., 2005; Singha Roy & Bandyopadhyay, 2016; Subhan et al., 2006). The oral medications, injections, ear and nose drops, and suppositories are non immune for patients who preferred fasting. Use of eye drops and inhalers is accepted as a process that does not nullify the fasting (Official Web site of The Presidency of Religious Diplomacy of the Republic of Turkey, n.d.). Despite this information, a considerable proportion of COPD patients adjust their medication regimens during RIF without asking their dr. (Fazel, 1998). For case, in a Turkish written report, the majority of the Muslim COPD patients quit using their medications during Ramadan (Aydin et al., 2014). In the present study, patients were asked most either to keep using their habitual medication or to adjust it in suhoor and iftar times. Only brusque-acting bronchodilators were stopped 6 to 8 60 minutes before the spirometry test. It seems that all inhaled medications used at iftar and suhoor times are not expected to subtract the efficacy of the drugs and this method "seems" to be suitable for patients who exercise not want to use their drugs throughout fasting hours (Aydin et al., 2014).

The present report presents four limitations. First, as washed in some relative studies (Adeli et al., 2015; Askari et al., 2016; Latiri et al., 2017; Moosavi et al., 2007; Siddiqui et al., 2005; Subhan et al., 2006), the convenience sampling was a confounding factor. For example, all patients were aware of the study aims, which might increase business concern most spiritual prejudice and then might stimulate fasters to make additional efforts in lung function testing. Convenience sampling tin undermine ability to make generalizations from the present sample to the population beingness studied. However, its low cost and ease of utilise make it the preferred choice for a significant number of researchers (Abdel-aziz & Ibraheem, 2008; Askari et al., 2016; Duncan et al., 1990; Latiri et al., 2017; Moosavi et al., 2007; Siddiqui et al., 2005; Singha Roy & Bandyopadhyay, 2016; Soori et al., 2016; Subhan et al., 2006). 2d, the noninclusion of a control-group of non-fasting COPD patients could be considered as a serious limitation because the internal power of the results from these studies and the changes in the variables assessed cannot be attributed exclusively to RIF (Fenneni et al., 2015; Latiri et al., 2017). In this regard, it has to be underlined that recruiting non-fasting groups in Muslim countries is not effortless, due to religious attitudes (Fenneni et al., 2014, 2015). Indeed, the study of Aydin et al. (2014) reported that patients with asthma or COPD do non feel their diseases to be an inhibitory cistron to fast Ramadan. Even so, among the 12 studies (Abdel-aziz & Ibraheem, 2008; Adeli et al., 2015; Askari et al., 2016; Bener et al., 2006; Duncan et al., 1990; Latiri et al., 2017; Moosavi et al., 2007; Norouzy et al., 2013; Siddiqui et al., 2005; Singha Roy & Bandyopadhyay, 2016; Soori et al., 2016; Subhan et al., 2006) demonstrating the "Hawthorne" effects of RIF on the lung role data of healthy and/or asthmatic adults, simply two performed in India and in Iran (Askari et al., 2016; Singha Roy and Bandyopadhyay, 2016) included control-groups. The remaining 10 studies conducted in Muslim countries (Iran, Saudi Arabia, Tunisia, Malaysia, Egypt, and Qatar) (Abdel-aziz & Ibraheem, 2008; Adeli et al., 2015; Bener et al., 2006; Duncan et al., 1990; Latiri et al., 2017; Moosavi et al., 2007; Norouzy et al., 2013; Siddiqui et al., 2005; Soori et al., 2016; Subhan et al., 2006) used Earlier-Ramadan values every bit control. Third, it was preferable to evaluate the hydration status and the diet government (particularly the medicinal herb/supplement use) of COPD patients for at least two reasons: (a) hypohydration causes a considerable raise in respiratory flow rates because of loss of h2o from the bronchovascular sheath and airway mucosa potentially reduce the airway resistance (Subhan et al., 2006); and (b) dietary abnormalities unfavorably influence the lung structure and function, the neural command of breathing and the functioning of the respiratory muscles (Riley & Thakker-Varia, 1995). Fourth, information technology was preferable to appraise the touch of RIF on some respiratory symptoms [using e.g., the COPD assessment tool (Vogelmeier et al., 2017)] or the COPD patients physical activity status' [since it influences the respiratory function (Cheng et al., 2003)] or the static volumes (very useful in the COPD direction).

Since RIF did not influence the weight of stable COPD patients, information technology seems unlikely that in the present report patients were dehydrated. In the studies evaluating the effects of RIF on the lung function data of salubrious patients (Abdel-aziz & Ibraheem, 2008; Duncan et al., 1990; Latiri et al., 2017; Moosavi et al., 2007; Siddiqui et al., 2005; Singha Roy & Bandyopadhyay, 2016; Soori et al., 2016; Subhan et al., 2006), confusing results, detailed in the Appendix, were noted for weight. Among the relative studies including asthmatic patients (Adeli et al., 2015; Askari et al., 2016; Bener et al., 2006; Norouzy et al., 2013), only one (Norouzy et al., 2013) looked into weight changes: it was lower at End-R compared to that obtained Before-R. A recent systematic review concluded that RIF could result in a significant weight loss of i.24 kg (Sadeghirad, Motaghipisheh, Kolahdooz, Zahedi, & Haghdoost, 2014). The heterogeneous findings regarding the effects of RIF on weight may be due to the varying of the patients' physical activity levels (Nematy et al., 2015).

Relative to Before-R data, in that location was no significant effect of RIF on spirometry data of stable COPD patients. While a few human studies have been conducted on the furnishings of RIF on the lung function data of healthy or asthmatic adults (Abdel-aziz & Ibraheem, 2008; Adeli et al., 2015; Askari et al., 2016; Bener et al., 2006; Duncan et al., 1990; Latiri et al., 2017; Moosavi et al., 2007; Norouzy et al., 2013; Siddiqui et al., 2005; Singha Roy & Bandyopadhyay, 2016; Subhan et al., 2006; Soori et al., 2016), or on drug apply behavior (Aydin et al., 2014; Wheatly & Shelly, 1993), no previous study has evaluated the effects of RIF on lung office data of COPD patients. Collectively, niggling consensus exists regarding the effects of RIF on the majority of chronic respiratory diseases (Kazemi et al., 2013). Therefore, making comparisons between literature is not relevant, due to several underlying confounding variables (Kazemi et al., 2013). The following paragraphs will discuss the effect of RIF on lung function information of good for you and asthmatic adults (Abdel-aziz & Ibraheem, 2008; Adeli et al., 2015; Askari et al., 2016; Bener et al., 2006; Duncan et al., 1990; Latiri et al., 2017; Moosavi et al., 2007; Norouzy et al., 2013; Siddiqui et al., 2005; Singha Roy & Bandyopadhyay, 2016; Subhan et al., 2006; Soori et al., 2016) and on drug-employ by COPD patients (Aydin et al., 2014; Wheatly & Shelly, 1993).

Results concerning the effects of RIF on lung function data of healthy adults, described elsewhere (Latiri et al., 2017) and described more in the Appendix, are contradictory. Briefly, while some studies reported that RIF doesn't alter spirometric data (Abdel-aziz & Ibraheem, 2008; Askari et al., 2016; Duncan et al., 1990; Latiri et al., 2017; Moosavi et al., 2007; Siddiqui et al., 2005; Singha Roy & Bandyopadhyay, 2016; Subhan et al., 2006; Soori et al., 2016), others reported that information technology impacted on some of them (Duncan et al., 1990; Siddiqui et al., 2005; Subhan et al., 2006; Moosavi et al., 2007). Most of the studies performed on asthmatic patients (Adeli et al., 2015; Askari et al., 2016; Bener et al., 2006; Norouzy et al., 2013) concluded that they can tolerate the RIF without pregnant amending of their spirometric flows [PEF (Adeli et al., 2015; Askari et al., 2016; Bener et al., 2006; Norouzy et al., 2013), MMEF (Adeli et al., 2015; Askari et al., 2016; Bener et al., 2006; Norouzy et al., 2013), FEF_75% (Askari et al., 2016), FEF_50% (Askari et al., 2016), FEF_25% (Askari et al., 2016)] or volumes [FEV₁ (Adeli et al., 2015; Askari et al., 2016; Bener et al., 2006; Norouzy et al., 2013), FVC (Askari et al., 2016; Bener et al., 2006; Norouzy et al., 2013)] or ratios [FEV₁/FVC (Adeli et al., 2015; Bener et al., 2006; Norouzy et al., 2013)]. Withal, 1 report (Norouzy et al., 2013) identified a significant increment in PEF past an average of 17% during the End-R session compared to the Before-R ane. In addition, it seems that hateful PEF variability decreased from xiii to 10%, respectively in the first and the quaternary weeks of Ramadan (Norouzy et al., 2013). Conclusions regarding the effects of RIF on clinical symptoms of asthmatic patients are also contradictory (Askari et al., 2016; Bener et al., 2006; Herrag et al., 2010; Norouzy et al., 2013). While some studies reported that RIF doesn't impact either their clinical symptoms (e.g., dyspnoea, coughing, wheezing, and chest tightness) (Askari et al., 2016; Norouzy et al., 2013) or their frequency of hospitalization (Bener et al., 2006), others identified a reduction in "objective wheezing" subsequently RIF (Askari et al., 2016) or noted an increase in the charge per unit of emergency consultations for astringent exacerbations (Herrag et al., 2010). Moreover, one study (Aydin et al., 2014) ended that fasting seems to be an important determining cistron in medication compliance by modifying the drug-apply behaviors in COPD and asthmatic patients. In contrast, a case-series study conducted on ii Muslims with chronic reversible respiratory illness, reported that the discontinuation of bronchodilators in Ramadan resulted in an acute exacerbation of their disease and their admission in the intensive care unit (Wheatly & Shelly, 1993). According to these authors (Wheatly & Shelly, 1993), Muslims with COPD should be enlightened that they put their health at risk when they abstain from taking their drugs for a long period of time.

How Can Changes in Lung Part Data During RIF Be Explained?

In the present written report, it may exist hypothesized that, the hydration status of the COPD patients was non disturbed and insignificant changes in the weight may have had some physiological impact on preserving the spirometric data during the RIF. In good for you or asthmatic patients, some hypotheses and/or mechanisms, largely described in the Appendix, were advanced to explicate the stability of spirometric data during RIF.

Recommendations and Perspectives

Despite the pilot nature of this study, some recommendations for physicians and patients, largely described in the Appendix, may exist advanced. They mainly business concern the few tips to give to COPD patients, who insist on fasting during Ramadan. Moreover, the nowadays paper is a call for more trials with relevant data from larger command-groups and more regular spirometric measurements throughout Ramadan.

To conclude, the chief finding of the present study reported that RIF did non bring about any significant change in the spirometric data of stable COPD male patients fasting the 2016 holy calendar month of Ramadan. This result emphasizes the need for practitioners to accept into account the patients' religious rituals and behavior when providing medical intendance.

Supplementary Material

Acknowledgments

Authors wish to express their sincere gratitude to all participants for their cooperation and for the post-obit two Pulmonologists from the Outpatient Pulmonology. Basic Health Group of Sousse, Tunisia: Raoudha SFAXI and Radhia ZAYANI. They as well wish to thank Professor Béchir SAADAOUI for his invaluable contribution in the comeback of the quality of the writing in the present paper.

Footnotes

List of Abbreviations: BMI: body mass index

COPD: chronic obstructive pulmonary disease

FEF_ten%: forced expiratory flow when X% of FVC has been exhaled

FEV₁ : 1st s forced expiratory volume

FVC: forced vital capacity

MMEF: maximal mid-expiratory period

mMRC: modified medical research council

PEF: peak expiratory period

R: Ramadan

RIF: Ramadan intermittent fasting

SD: standard deviation

Declaration of Conflicting Interests: The author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: HBS reports personal fees from AstraZeneca, Boehringer Ingelheim, GSK and Chiesi. The remaining authors declare that they have no conflicts of interest concerning this article.

Funding: The author(southward) received no fiscal support for the research, authorship, and/or publication of this commodity.

Supplemental Textile: Supplementary material is available for this commodity online.

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Source: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5818112/

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