Journal of Sports Sciences, December 2008; 26(S3): S29–S38

Dietary intake and body composition of football players during the holy month of Ramadan

RONALD J. MAUGHAN1, ZAKIA BARTAGI2, JIRI DVORAK3, & YACINE ZERGUINI4
School of Sport and Exercise Sciences, Loughborough University, Loughborough, UK, 2National Centre for Medicine and Scientific Research in Sport, Tunis, Tunisia, 3FIFA Medical Assessment and Research Centre, Schulthess Clinic, Zurich, ´ Switzerland and 4Centre d’Evaluation et d’Expertise en Medecine du Sport, Algiers, Algeria (Accepted 14 August 2008)
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Abstract Healthy young male football players who were either fasting (n ¼ 59) or not fasting (n ¼ 36) during the month of Ramadan were studied. Body mass, body composition, and dietary intake were assessed at each time point. Energy intake was relatively stable in the fasting participants, but there was a small decrease of approximately 0.7 kg in body mass during Ramadan. Mean daily energy intake increased from 14.8 MJ (s ¼ 2.9) to 18.1 MJ (s ¼ 3.2) during Ramadan in non-fasting participants, with concomitant increases in body mass and body fat content of about 1.4 kg and 1% respectively over the month. The fractional intake of protein increased and the fractional contribution of carbohydrate decreased for both groups in Ramadan. Estimated mean daily water intake was high (about 3.8 litres) throughout the study period. Water intake increased on average by 1.3 litres Á day71 in line with the greater energy intake in the non-fasting group in Ramadan. Daily sodium intake fell during Ramadan in the fasting participants from 5.4 g (s ¼ 1.1) before Ramadan to 4.3 g (s ¼ 1.0) during Ramadan, but increased slightly by about 0.7 g Á day71 in the non-fasting group. Dietary iron decreased in the fasting group and increased in the non-fasting group, reflecting the difference in energy intake in both groups during Ramadan. These data suggest that Ramadan fasting had some effects on diet composition, but the effects were generally small even though the pattern of eating was very different. After Ramadan, the dietary variables reverted to the pre-Ramadan values.

Keywords: Ramadan fasting, body composition, energy intake, carbohydrate

Introduction One of the most obvious effects of the observation of the holy month of Ramadan is a change in dietary practice, with the intake of food and fluid being avoided during the hours of daylight for the duration of the month. This involves a change in the timing of food intake, and a disruption of the normal circadian rhythm. These changes can lead to a reduction in total energy intake and a loss of body mass (Husain, Duncan, Cheah, & Ch’ng, 1987; Sweileh, Schnitzler, Hunter, & Davis, 1992; Ziaee et al., 2006), but other researchers have found no change in these variables (Beltaifa et al., 2002; Finch, Day, Welch, & Rogers, 1998; Karli, Guvenc, Aslan, Hazir, & Acicada, 2007; Meckel, Ismaeel, & Eliakim, 2008). To further confuse the picture, Chaouachi et al. (2008) reported that energy intake of young elite judo athletes remained constant during Ramadan but observed significant losses in body mass and body fat. For

those involved in sport, there are some clear implications for performance in both training and competition. Although there have been several studies on the nutritional, metabolic, and body composition changes during the month of Ramadan, there has been little work on the responses in athletes who continue to train throughout this period. Meckel et al. (2008), however, reported no change in energy intake during the month of Ramadan, but did observe some negative effects on components of performance in young football players. The duration of each day’s period of fasting during Ramadan is relatively short, and it is not entirely clear whether short periods of fasting have any effect on competitive sports performance, although it is well established that carbohydrate oxidation is decreased and fatty acid oxidation increased by even a few hours of fasting (Coyle, Coggan, Hemmert, Lowe, & Walters, 1985). There is anecdotal evidence of an increase in road traffic accidents during

Correspondence: R. J. Maughan, School of Sport and Exercise Sciences, Loughborough University, Loughborough LE11 3TU, UK. E-mail: r.j.maughan@lboro.ac.uk ISSN 0264-0414 print/ISSN 1466-447X online Ó 2008 Taylor & Francis DOI: 10.1080/02640410802409675

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R. J. Maughan et al. covered here only briefly. Dietary data were collected from 95 (59 fasting, 36 non-fasting) healthy young male volunteers who played football for one or other of four teams based in Tunis. The nature of the study was explained to all participants, who then gave their written consent to participate. Ethical approval was granted by the National Research Ethics Committee. Throughout the study period, players trained or played in competitive matches on a daily basis. In the last week before Ramadan, only one team trained in the morning (at approximately 10.00 h; n ¼ 22) and the rest in the afternoon (at approximately 18.00 h; n ¼ 73), but in the 2-week period prior to this, two of the teams trained in the morning and two in the afternoon. During Ramadan, all four teams trained in the afternoon (between 13.00 and 18.00 h). Training varied on a daily basis, but typically lasted about 60 min. Ramadan began on 23 September 2006, and the body composition measurements reported here were made during the week before the beginning of Ramadan, during weeks 2 and 4 of Ramadan, and again 3 weeks after the end of Ramadan. The climatic conditions varied little on a daily basis over the study period. For the month of October, the average temperature was 268C, with a daily average minimum temperature of 188C and an average maximum temperature of 288C. Average relative humidity was 72%, and total rainfall during the month was 49 mm. During the initial measurement period, all participants in the study were provided with breakfast at approximately 07.30 h, lunch at 12.30 h, and dinner at 18.30 h. The non-fasting group maintained this eating schedule throughout, but during Ramadan the fasting group were provided with a meal between 04.00 and 07.00 h (before sunrise – Souhour) and another meal between 19.00 and 20.00 h (Foutour). Snacks and drinks were permitted at other times, but the fasting group abstained from all food and fluid between Souhour and Foutour. During Ramadan, special meals were provided for the fasting players to break their fast, and these were available also to the non-fasting players. Dietary intake of foods and nutrients was assessed before, during, and after Ramadan using a 24-h recall method on each occasion for three separate days during each of the three phases of the study (Bingham & Nelson, 1991), which was completed by interview with the same experienced dietician. The 3-day record has been shown to be accurate to within 10% of the energy intake values obtained with 7-day records (Burnett, O’Connor, Koltyn, Raglin, & Morgan, 1994). A standard format was used for each 24-h recall according to the principles described in Cameron and van Staveren (1988). Players were asked to report, in as detailed a manner as possible, all foods and fluids consumed during the preceding

Ramadan (Arab News, 2007) and some evidential support for the idea that lifestyle changes around Ramadan may lead to an increase in accidents (Tolon & Chernoff, 2006). This implies some loss of cognitive function and/or motor control, both of which are important elements of performance in many sports. Under controlled laboratory conditions, moderate periods of fasting (i.e. 24–36 h) have been shown to impair endurance (Maughan & Gleeson, 1988) and high-intensity (Gleeson, Greenhaff, & Maughan, 1988) exercise performance. It is recognized that the intakes of protein, amino acids, and carbohydrate in the period just before or just after training will influence the rates of protein synthesis and degradation (Tipton et al., 2001). This, in turn, can influence the metabolic and functional adaptations taking place in response to the training stimulus (Andersen et al., 2005; Candow, Burke, Smith-Palmer, & Burke, 2006). Most sports nutrition guidelines recommend intake of protein (Hawley, Tipton, & Millard-Stafford, 2006), carbohydrate (Burke, Loucks, & Broad, 2006), and fluid (Shirreffs, Sawka, & Stone, 2006) in the period after training to promote recovery and to stimulate the process of adaptation taking place within the exercised muscles. These may have long-term consequences, but where there is adequate time for recovery, the need for food and fluid intake in the immediate post-exercise period is less urgent. The absence of fluid intake over the course of the day may have greater implications for performance than the absence of food intake. Daily water turnover for sedentary individuals living in a temperate climate is typically about 2–3 litres, but this may increase several-fold for active individuals exposed to hot climates (Maughan & Shirreffs, 2004). Although there is much debate about the effects of mild hypohydration on exercise performance (Noakes, 2007; Sawka et al., 2007), there is no doubt that both physical and mental performance will be impaired if hypohydration is sufficiently severe. Where either exercise or heat exposure is unavoidable during the day, it is therefore likely that an individual who avoids fluid intake over the course of a day will perform less well if called upon to exercise late in the day. The combined effects of food and fluid restriction are therefore of importance to the Muslim athlete who must train and compete throughout Ramadan. The aim of this part of the study was to assess changes in dietary intake, body mass, and body composition in young professional football players over the course of Ramadan. Methods and materials The general methods and materials for this study are described elsewhere (Leiper et al., 2008) and are

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Nutritional effects of Ramadan fasting 24 h. For each food item mentioned by the players, further information was asked about its type, the size of the portion, and the amount consumed, with twoand three-dimensional food models being shown to help the interviewee in his estimation. Dietary records were analysed for energy intake by the use of a food database created in the National Centre for Medicine and Scientific Research in Sport, Tunis, with values based mainly on the food composition tables published by the National Institute of Statistics of Tunisia in 1978 and on other published data (Food Standards Agency, 2002). Body mass was measured to the nearest 100 g with an electronic balance (Seca Instruments Ltd., Hamburg, Germany) and standing height was determined to the nearest 0.001 m using a stadiometer. The percentage of body fat mass was estimated from four measurements of skinfold thickness (Harpenden caliper, Lange, Cambridge, MA, USA) using the Durnin and Womersley (1974) equation. Statistical analysis of all the data was assessed using the Statistical Package for the Social Sciences (SPSS). The data were initially tested for distribution (Shapiro-Wilks test) and homogeneity of variance (Levene’s test). Where the assumption that the data were normally distributed was reasonably met, the data were analysed using two-way or oneway analysis of variance (ANOVA) as appropriate. Where applicable, this was followed by application of the Tukey multiple range test to assess any differences between groups or phases in the study. All the data in the present study were found to be essentially normally distributed and are reported as means and standard deviations. All tests were twotailed and statistical significance was set at P 5 0.05. Results

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The descriptive data were checked and found to be normally distributed. The fasting (n ¼ 59) and nonfasting (n ¼ 36) groups at the start of the study were found to be matched for age (P ¼ 0.66), body mass (P ¼ 0.13), height (P ¼ 0.75), body mass index (P ¼ 0.07), and percent body fat content (P ¼ 0.87) (Table I). Body mass and body composition Relative to the pre-Ramadan measure, body mass (Table II) had marginally decreased in the fasting group by the second week of Ramadan (P ¼ 0.002) and remained at this level in the last week of Ramadan (P ¼ 0.88). In the non-fasting group, body mass had increased (P 5 0.001) by the second week of Ramadan and was slightly higher still in the last week of Ramadan (P 5 0.001). This resulted in an overall increase in average body mass for the nonfasting group of about 1.4 kg during the month of Ramadan. However, no differences could be detected in body mass between the two groups at each measurement occasion during the study (P ¼ 0.74). Based on the time of day when the players were weighed, the body mass of the players measured in the morning and those measured in the afternoon remained similar in the fasting group (P ¼ 0.59) and in the non-fasting group (P ¼ 0.81) throughout the study (Table III). No differences in body mass were detected between the fasting and non-fasting group when compared by time of day of measurement throughout the study (P ¼ 0.83). Compared with the body fat content measured before Ramadan (Table IV), no differences were

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Table I. Baseline participant characteristics (mean, standard deviation in parentheses, and range in brackets). Parameter Age (years) Body mass (kg) Height (m) BMI (kg Á m72) Body fat (%) Fasting group (n ¼ 59) 18 (1) [17–21] 71.9 (8.5) [58.0–94.5] 1.78 (0.06) [1.66–1.89] 22.8 (2.3) [17.9–31.0] 12.3 (3.5) [6.6–21.7] Non-fasting group (n ¼ 36) 18 (1) [17–20] 69.6 (7.4) [54.5–86.1] 1.78 (0.06) [1.65–1.91] 21.8 (1.8) [18.5–24.7] 12.4 (2.8) [8.3–18.4]

Table II. Body mass (kg), body fat content (%), and BMI (kg Á m72) measured during the study (mean values with standard deviations in parentheses). Fasting group (n ¼ 59) Study week Before Ramadan Week 2 of Ramadan Week 4 of Ramadan Body mass 71.9 (8.5) 71.2 (8.5)** 71.1 (8.0)** Body fat 2.3 (3.5) 12.3 (3.9) 12.1 (3.5) BMI 2.8 (2.3) 22.4 (2.3) 22.6 (2.3) Non-fasting group (n ¼ 36) Body mass 69.6 (7.4) 70.2 (7.6)*** 71.0 (7.6)*** Body fat 12.4 (2.8) 13.1 (3.0)* 13.4 (2.9)* BMI 21.8 (1.8) 21.8 (2.7) 22.4 (2.0)

Note: Compared with the pre-Ramadan value: *P 5 0.05; **P 5 0.005; ***P 5 0.001.

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Table III. Body mass (kg) measured in the morning (am) or afternoon (pm) during the study (mean values with standard deviations in parentheses). Fasting group Study week Before Ramadan Week 2 of Ramadan Week 4 of Ramadan am (n ¼ 34) 72.4 (6.8) 71.9 (7.1) 72.2 (7.1) pm (n ¼ 25) 71.1 (10.8) 70.1 (10.5) 69.5 (9.1) Non-fasting group am (n ¼ 19) 69.8 (8.6) 70.6 (8.9) 71.5 (8.8) pm (n ¼ 17) 68.6 (6.2) 69.8 (6.3) 70.5 (6.5)

Table IV. Body fat (%) measured in the morning (am) or afternoon (pm) during the study (mean values with standard deviations in parentheses). Fasting group Study week Before Ramadan Week 2 of Ramadan Week 4 of Ramadan am (n ¼ 34) 13.0 (2.9) 13.1 (3.4) 12.8 (3.0) pm (n ¼ 25) 11.2 (4.1) 11.0 (4.2) 11.2 (4.4) Non-fasting group am (n ¼ 19) 12.6 (3.1) 13.5 (3.7) 14.0 (3.6) pm (n ¼ 17) 12.2 (2.6) 12.7 (2.3) 12.8 (1.9)

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found in body fat in the fasting (P ¼ 0.37) group during the second and last week of Ramadan. In contrast, players in the non-fasting group increased their percent body fat slightly during the first half of Ramadan (P ¼ 0.03) and maintained this level of adiposity throughout the rest of the study (P ¼ 0.60). Percent body fat was, however, similar between the two groups on each measurement occasion during the study (P ¼ 0.17). Based on the time of day when the players were measured (Table IV), percent body fat content of the players measured in the morning and those measured in the afternoon remained similar in the non-fasting group throughout the study (P ¼ 0.53). There was a tendency for percent body fat to be greater in the fasting group of players measured in the morning than those in the afternoon before Ramadan (P ¼ 0.09) and in the second week (P ¼ 0.06) but not in the fourth week of Ramadan (P ¼ 0.12). The percent body fat of the fasting group of players measured in the morning was similar throughout the study (P ¼ 0.73), as was that of the players measured in the afternoon (P ¼ 0.81). Compared with the body mass index (BMI) measured before Ramadan, no change was found in BMI in the fasting (P ¼ 0.56) or non-fasting (P ¼ 0.42) groups during the second or last week of Ramadan. The BMI was similar between the two groups on each measurement occasion during the study (P ¼ 0.49). Based on the time of day when the players were measured, the BMI of the players measured in the morning and those in the afternoon remained similar in the fasting group throughout the study (P ¼ 0.31). However, the BMI in the nonfasting players measured in the morning was slightly lower than that of the players measured in the afternoon (P ¼ 0.03) throughout the study. No significant difference was detected on any of the

Table V. Daily energy intake (MJ Á day71) (mean values with standard deviations in parentheses). Pre-Ramadan Fasting Non-fasting 14.6 (2.4) 14.8 (2.9) Ramadan 14.2 (2.7) 18.1 (3.2){# Post-Ramadan 14.8 (3.3) 14.4 (2.5)

Note: Compared with the pre-Ramadan value: {P 5 0.001. Compared with the fasting group during Ramadan: #P 5 0.001.

measurement occasions in the BMI values measured in the morning (P ¼ 0.75) or in the afternoon (P ¼ 0.62) in the non-fasting group or fasting group (P ¼ 0.84 and P ¼ 0.73, respectively) during the study. Energy and macronutrient intake Dietary recall data for this part of the study were complete for all 95 players before and during Ramadan. In the period after Ramadan, dietary data for 86 (52 fasting group, 34 non-fasting group) players were collected. Estimated mean daily energy intake before Ramadan was similar (P ¼ 0.65) in the fasting and nonfasting groups (Table V). Overall during Ramadan, the players in the non-fasting group increased (P 5 0.001) their daily energy intake by an average of 3.3 MJ (s ¼ 3.5), while that of the fasting group remained essentially the same as before Ramadan (P ¼ 0.47). The increase in energy intake in the nonfasting group meant that the energy intake of this group was higher than that of the fasting group during Ramadan (P 5 0.001). After Ramadan, the energy intake of the fasting (P ¼ 0.38) and nonfasting (P ¼ 0.72) groups returned to essentially their pre-Ramadan values and were similar in the two groups (P ¼ 0.91).

Nutritional effects of Ramadan fasting The estimated daily amount of carbohydrate in the diet was similar on all measurement occasions in the fasting group (P ¼ 0.29; Table VI). Dietary carbohydrate intake was similar in the fasting and non-fasting group before Ramadan (P ¼ 0.35). During Ramadan, carbohydrate intake was higher in the nonfasting group than it was before Ramadan (P 5 0.001), after Ramadan (P 5 0.001), and compared with the intake of the fasting group at the same time point (P 5 0.001). There was no difference in the estimated dietary carbohydrate intake between the fasting and non-fasting players after Ramadan (P ¼ 0.39) or between pre- and post-Ramadan values for the fasting (P ¼ 0.82) and non-fasting (P ¼ 0.86) groups. The estimated proportion of daily energy supplied by carbohydrate in the players’ diet was similar in the two groups before Ramadan (P ¼ 0.11), and remained similar during (P ¼ 0.76) and after (P ¼ 0.16) Ramadan. In the fasting group, the fractional contribution of carbohydrate to the daily diet was marginally greater before than during Ramadan (P 5 0.001). Similarly, the proportion of carbohydrate in the diet of the non-fasting group was slightly greater before than during Ramadan (P 5 0.001). After Ramadan, the percentage of carbohydrate in the diet had essentially returned to that consumed in the period before Ramadan in both the fasting (P ¼ 0.93) and non-fasting (P ¼ 0.77) groups. The estimated daily amount of protein in the diet was similar (P ¼ 0.80) before Ramadan in the fasting and non-fasting groups (Table VII). During Ramadan, the protein content of the diet in the non-fasting

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group was higher than that before Ramadan (P 5 0.001), and was higher than that in the fasting group at the same period (P 5 0.001). In the fasting group, daily protein intake during Ramadan was slightly greater than before Ramadan (P 5 0.001). After Ramadan, the amount of protein in the diet returned to pre-Ramadan values in both the fasting (P ¼ 0.08) and non-fasting (P ¼ 0.68) groups, which were similar (P ¼ 0.35). The estimated proportion of daily energy supplied by protein in the players’ diet was similar in the two groups (P ¼ 0.40) before Ramadan. In the fasting group, the percentage of protein in the daily diet was greater during Ramadan (P 5 0.001) than before Ramadan. Similarly, the proportion of protein in the diet of the non-fasting group was greater during Ramadan (P 5 0.001) than before Ramadan. The percentage of protein in the diet was similar for fasting and non-fasting players during Ramadan (P ¼ 0.99). After Ramadan, the percentage of daily energy supplied by protein returned to pre-Ramadan values in the non-fasting (P ¼ 0.54) and fasting (P ¼ 0.40) groups, which were similar (P ¼ 0.08). The estimated daily amount of fat in the diet was similar (P ¼ 0.59) before Ramadan in the fasting and non-fasting groups (Table VIII). During Ramadan, the dietary fat content of the non-fasting group increased relative to that before Ramadan (P 5 0.001), and was higher than that of the fasting group at the same period (P 5 0.001). Estimated daily fat intake in the fasting group was similar before and during Ramadan (P ¼ 0.97). After Ramadan, estimated daily fat intake was essentially the same as

Table VI. Estimated daily carbohydrate (g) content of the diets and estimated fraction of total energy intake accounted for by carbohydrate (mean values with standard deviations in parentheses). Pre-Ramadan g Fasting Non-Fasting 489 (90) 508 (101) % 55 (4) 57 (4) g 482 (83) 579 (115){# Ramadan % 52 (4){ 52 (4){ g 481 (106) 504 (79) Post-Ramadan % 55 (4) 57 (5)

Note: Compared with the pre-Ramadan value: {P 5 0.001. Compared with the fasting group during Ramadan: #P 5 0.001.

Table VII. Estimated daily protein content (g) of the diets and estimated fraction of total energy intake accounted for by protein (mean values with standard deviations in parentheses). Pre-Ramadan g Fasting Non-fasting 116 (21) 115 (22) % 13 (2) 13 (1) g 126 (27){ 158 (29){# Ramadan % 16 (1){ 16 (1){ g 123 (36) 117 (25) Post-Ramadan % 14 (2) 13 (2)

Note: Compared with the pre-Ramadan value: {P 5 0.001. Compared with the fasting group during Ramadan: #P 5 0.001.

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Table VIII. Estimated daily fat (g) content of the diets and estimated fraction of total energy intake accounted for by fat (mean values with standard deviations in parentheses). Pre-Ramadan g Fasting Non-fasting 123 (22) 120 (29) % 31(3) 30 (3) g 124 (24) 158 (39){# Ramadan % 33 (3) 32 (3){ g 122 (33) 118 (31) Post-Ramadan % 31 (3) 30 (4)

Note: Compared with the pre-Ramadan value: {P 5 0.05; {P 5 0.001. Compared with the fasting group during Ramadan: #P 5 0.001.

Table IX. Estimated total daily water intake (litres) from foods and fluids (mean values with standard deviations in parentheses). Pre-Ramadan Fasting Non-fasting
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Ramadan 3.66 (0.73) 5.17 (0.75){#

Post-Ramadan 3.48 (0.98) 3.68 (0.99)

3.85 (0.91) 3.86 (0.91)

Note: Compared with the pre-Ramadan value: {P 5 0.001. Compared with the fasting group during Ramadan: #P 5 0.001.

Table X. Estimated daily sodium (mg) and iron (mg) content of the diets (mean values with standard deviations in parentheses). Pre-Ramadan Sodium Fasting Non-fasting 5369 (1129) 4950 (1190) Iron 27 (6) 25 (5) Sodium 4299 (970){ 5674 (1139){# Ramadan Iron 22 (4) 27 (5) Post-Ramadan Sodium 5173 (1420) 4752 (1137) Iron 26 (6) 24 (6)

Note: Compared with the pre-Ramadan value: {P 5 0.001. Compared with the fasting group during Ramadan: #P 5 0.001.

that before Ramadan in the fasting (P ¼ 0.86) and non-fasting (P ¼ 0.85) groups, and was similar for the two groups (P ¼ 0.59). The estimated proportion of daily energy supplied by fat in the players’ diets was similar in the two groups (P ¼ 0.11) before Ramadan. In the fasting group, the estimated percentage of fat in the diet during Ramadan was similar (P ¼ 0.093) to that before Ramadan. The proportion of energy supplied by fat was marginally greater in the non-fasting group during Ramadan (P ¼ 0.02) than before Ramadan, but similar to that in the fasting group at the same time point (P ¼ 0.06). After Ramadan, the estimated percentage of fat in the diet was essentially the same as before Ramadan in the fasting (P ¼ 0.36) and nonfasting (P ¼ 0.58) groups, with the two groups similar (P ¼ 0.21). Estimated daily total water intake from ingested food and fluids before Ramadan was similar (P ¼ 0.86) in the two groups (Table IX). Estimated daily total water intake of the fasting group remained essentially the same before and during Ramadan (P ¼ 0.17). In the non-fasting group, total water intake increased during Ramadan compared with before Ramadan (P ¼ 0.01). Estimated daily water

intake was therefore greater during Ramadan in the non-fasting group than in the fasting group (P 5 0.001), but was similar between the two groups after Ramadan (P ¼ 0.45). Estimated daily dietary sodium intake before Ramadan was similar (P ¼ 0.09) in the two groups (Table X). Compared with before Ramadan, estimated sodium intake of the fasting group was lower during Ramadan (P 5 0.001), while it was higher in the non-fasting group (P ¼ 0.006). This resulted in a significant difference between the two groups during Ramadan (P 5 0.001). After Ramadan, sodium intake returned to pre-Ramadan values in both the fasting (P ¼ 0.43) and non-fasting (P ¼ 0.55) groups, which were similar (P ¼ 0.15). The estimated daily iron intake from the diet was similar (P ¼ 0.08) in the two groups before Ramadan (Table X). Compared with before Ramadan, daily dietary intake of iron was lower during Ramadan in the fasting group (P 5 0.001), while it was higher in the non-fasting group (P ¼ 0.02). Intake during Ramadan was therefore significantly different between the two groups during this phase of the study (P 5 0.001). After Ramadan, the intake of dietary iron was similar to that ingested before Ramadan in

Nutritional effects of Ramadan fasting both the fasting (P ¼ 0.45) and non-fasting (P ¼ 0.31) groups, which were similar (P ¼ 0.08). Discussion Changes in energy intake and the dietary intakes of macro- and micro-nutrients during the period of Ramadan were generally rather small. Similarly, there was no profound effect on body mass or on body composition, although some subtle changes were observed. It is important to note the limitations to the sensitivity of the methodologies used, and changes in body composition over this short timescale are unlikely to be detected reliably, while changes in body mass will be influenced by the normal day-to-day variations in hydration status that occur. The results of this study are consistent with numerous reports in the literature that suggest that neither energy intake nor body mass changes substantially during Ramadan fasting. Ramadan (2002) reported that no change in body composition occurred during observance of Ramadan in a group of healthy but sedentary adult males, suggesting that energy intake was not affected. El Ati and colleagues (El Ati, Beji, & Danguir, 1995) also reported that energy intake and body composition did not change in female players during Ramadan. Ramadan and colleagues (Ramadan, Telahoun, Al-Zaid, & BaracNieto, 1999) observed no statistically significant change in body mass during Ramadan in small samples of active and sedentary players. Maislos and colleagues (Maislos, Khamaysi, & Assali, 1993) reported similar findings. More recently, Furuncuoglu and colleagues (Furuncuoglu, Ender, Sukru, & ¨ ¨ Arif, 2007) reported no change in body mass in 39 players during 26 days of fasting when the mean duration of fasting each day was 14 h. Yucel and colleagues (Yucel, Degirmenci, Acar, Albayrak, & Haktanir, 2004) found no effect of Ramadan fasting on body mass or abdominal fat distribution, as assessed by computed tomography scanning, in a mixed group of males and females, but they did find small reductions in the visceral fat compartment in female participants and in young participants. In contrast to these observations, there are a number of reports of reduced energy intake and/or loss of body mass during Ramadan. Sweileh et al. (1992) reported that participants experienced a reduction in body mass of 1.92 kg and a decrease in body fat content with no loss of lean tissue. They reported an exceptionally low daily energy intake (1220 kcal Á day71) during Ramadan, but no data were provided to indicate the participants’ normal intakes. Most (1.13 kg) of the body mass loss occurred during the first week, and based on changes in blood parameters the authors concluded that a state of dehydratation existed during the first week of

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Ramadan, although this returned to normal by the end of the month. Sulemani (1988) and Fedail and colleagues (Fedail, Murphy, Salih, Bolton, & Harvey, 1982) also reported a total reduction of about 1 kg in body mass during Ramadan. In a group of 10 adult male university professors in Pakistan, mean energy intake fell by 857 kcal (s ¼ 410) during Ramadan, and body mass fell by 3.2 kg (s ¼ 1.7) over the month (Khan and Khattak, 2002). In a small (n ¼ 9) group of young male rugby players, a significant fall in energy intake, accompanied by falls in body mass and in body fat content, was observed at the end of Ramadan by Bouhlel et al. (2006). There are reports of increased energy intake during Ramadan in Saudi Muslims (Frost & Pirani, 1987) and decreases in Indian Muslims (Chandalia, Bhargau, & Kataria, 1987), suggesting that there may be regional and cultural variations in dietary practices. It is important to note also that the participants in the study of Chandalia and colleagues were diabetic, and a reduced total energy intake may reflect changes in the composition of the foods on offer at this time. In the present study, the nonfasting players were more likely to change dietary habits, body mass, and body composition during Ramadan and an increase, rather than a decrease, in food intake was observed. The reported values for energy intake and dietary composition during the pre-Ramadan period are similar to many of the values reported for football players in the literature. Energy intake of a typical male player is about 13–16 MJ Á day71, equivalent to 160–200 kJ Á kg71 Á day71 (Burke et al., 2006). These intake data, however, are prone to reporting error and to fluctuations across the competitive season, making comparisons between data sets difficult. There was a significant increase in the energy intake (by 3.3 MJ Á day71) of the non-fasting players during Ramadan, and this reflected the mixed social setting, whereby non-fasting players tended to eat their own meals and then join their fasting colleagues for a further meal. This behaviour was most apparent during the first week of Ramadan, suggesting a high degree of self-regulation of energy intake once the initial novelty wore off. The higher energy intake resulted in an increase of about 1.3 kg in body mass over the month of Ramadan. However, while the rise in body mass over the first half of Ramadan (*0.6 kg) appeared to be entirely due to an augmentation in body fat (*0.6 kg), the further increase of approximately 0.7 kg in body mass during the second half of Ramadan was apparently accompanied by an increase of only 0.3 kg of body fat. This might be due to a change in glycogen storage, hydration status or other lean tissue components, allied to measurement errors and random

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R. J. Maughan et al. fasting adolescent Tunisian football players in the present study appear to have followed a pattern of food intake that is similar to that of the sedentary Tunisian women reported by El Ati and colleagues (1995). This is presumably due to the type of foods that are traditionally eaten by Tunisians during Ramadan. The mean values for dietary protein intake also tend to suggest that players are achieving target intakes, as mean daily protein intake was typically about 1.6–1.8 g Á kg71. This is about the upper end of the recommended range for athletes in all sports (Tarnopolsky, 2004) and also at the upper end of the recommended range for football players (Hawley et al., 2006; Lemon, 1994). It is also similar to other values reported in the literature for protein intakes of football players (Maughan, 1997; Rico-Sanz et al., 1998). The fractional contribution of protein to energy intake was highest during Ramadan. Once again, however, it is important not to let the mean values deflect attention from those individuals at the extremes of the ranges. Some players had rather low protein intakes, although there is no suggestion that these were inadequate. The available evidence suggests that nitrogen balance can be maintained with a wide range of protein intakes provided that energy intake is adequate (for a review, see Tipton & Witard, 2007). The average daily water intake of these players was relatively high compared with values typically ob˚ served in young men (Astrand & Rodahl, 1986), but was not especially high compared with total daily water turnover values measured in active men living in a temperate climate (Leiper, Carnie, & Maughan, 1996). The water losses of players in training can be high, especially in warm environmental conditions: some players may lose more than 3 litres of sweat during a single training session (Shirreffs et al., 2006). The fluid balance of players in this study is discussed in more detail by Shirreffs and Maughan (2008). The dietary sodium intake of the fasting players fell during Ramadan even though energy intake was maintained, suggesting a lower salt content of the foods eaten at this time. Even though the total energy intake increased in the non-fasting group during Ramadan, their sodium increased less than might have been expected. This is consistent with a lower salt content of the foods prepared for the fasting players, as the non-fasting players tended to consume some of these foods in addition to their own meals during Ramadan. Salt intakes are generally quite high, relative to guidelines for sedentary individuals (Scientific Advisory Committee on Nutrition, 2003; Institute of Medicine, 2005), and this is discussed in more detail by Shirreffs and Maughan (2008). There was a fall in dietary iron intake during Ramadan in the fasting group, but this is unlikely to

fluctuations. Changes in bowel and bladder habits may also play some role. There was a substantial increase in the carbohydrate intake of the non-fasting players during Ramadan, due mainly to the increased total energy intake rather than to any major change in the composition of the diet. Intakes of fat and protein also increased in the non-fasting group during Ramadan. The increase in carbohydrate intake averaged 70 g Á day71, or about 1.0 g Á kg71 Á day71. Throughout the study, the carbohydrate intake of both the fasting and nonfasting players was about 7–8 g Á kg71 Á day71. This is consistent with the recommendation that players should eat about 5–7 g Á kg71 Á day71 during periods of light training and 7–12 g Á kg71 Á day71 during periods of heavy training (Burke et al., 2006; Hawley et al., 2006), and suggests that the normal dietary carbohydrate intake of these players is probably adequate to sustain their training. It is important to recognize, however, that these are mean values and it may be misleading to focus on such values because there was a large inter-individual variability in both total energy intake and in the composition of the diets eaten. While some players achieved high carbohydrate intakes, some failed to do so. Thirty-five players in the present study reported carbohydrate intakes of 6 g Á kg71 Á day71 or less during the pre-Ramadan period. The change in the composition of foods during Ramadan meant that there was a slight decrease in the contribution of carbohydrate to energy intake, with increased relative contributions of protein and fat, at this time in both groups. However, the amount of carbohydrate ingested by most of the fasting players appeared to be sufficient for the training load that they undertook: there were no changes over time in the performance tests that the players completed during this study (Kirkendall, Leiper, Zerguini, Bartagi, & Dvorak, 2008). There was, nevertheless, a trend for the fasting players to lose on average about 0.7 kg over the first half of Ramadan. While this might suggest that energy intake was slightly less than the energy expenditure required by the players, it is more likely that the apparent weight loss of about 1% of body mass was due to the acute dehydration that is known to occur throughout the hours of daylight during Ramadan (Cheah, Ch’ng, Husain, & Duncan, 1990; Leiper, Molla, & Molla, 2003). In a population of healthy but sedentary Tunisian women, El Ati et al. (1995) reported an increase in the relative content of fat and protein in the diet during Ramadan, with a corresponding decrease in carbohydrate as total energy intake was unchanged. It is clear, however, that there are considerable cultural differences in the observation of Ramadan, and the types of foods eaten may or may not differ markedly from the normal dietary pattern. The

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Nutritional effects of Ramadan fasting be of any clinical significance, for two reasons. First, the dietary iron intakes of all players were relatively high compared with the recommended intakes. The US recommended dietary allowance for iron is 8 mg Á day71 for men (Panel on Micronutrients, 2001), while the Reference Nutrient Intake in the UK is 9 mg Á day71 for young men (Department of Health, 1991). Even the lower value in the fasting players during Ramadan is well in excess of this. Second, even if there was a reduction during Ramadan in some players, the relatively short duration of this altered food intake pattern would be unlikely to substantially alter iron status. In conclusion, our results show that there were some small changes in body mass and body composition over the course of Ramadan, but these changes were generally small and of limited physiological significance. Ramadan fasting had some effects on diet composition, but the effects were generally small even though the pattern of eating was very different. After Ramadan, the dietary variables reverted to pre-Ramadan values. Acknowledgements The costs of this study were met by grants from FMARC (FIFA Medical Assessment and Research Centre) and from the Tunisian Football Federation. R. J. Maughan is a member of the Science Advisory Board of the Gatorade Sports Science Institute, for which he receives a small honorarium. None of the other authors has a real or potential conflict of interest to declare. References
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