Original Paper
Eur Neurol 2009;61:230–232
DOI: 10.1159/000197108
Short-Term Effects of Prolonged Fasting
on Multiple Sclerosis
Mohammad Saadatnia a, c Masoud Etemadifar a–c Farzad Fatehi a–c Fereshteh Ashtari a, c
Vahid Shaygannejad a, c Ahmad Chitsaz a, c Amir Hadi Maghzi a–c
a
Neurology Department, Alzahra Hospital, Isfahan University of Medical Sciences,
b
Isfahan Research Committee of MS, c Isfahan Neurosciences Research Center, Isfahan, Iran
Key Words
Multiple sclerosis ⴢ Fasting ⴢ Uric acids ⴢ Low-density
lipoprotein
Abstract
Fasting during Ramadan is mandatory for all healthy Muslim
adults. During the fasting month, many physiological and
biochemical changes occur that may be due to alterations in
eating and sleeping patterns. A concern for Muslim multiple
sclerosis (MS) patients is whether prolonged fasting might
have an unfavorable impact on the course of their disease.
The aim of this prospective study was to determine the ef-
fects of prolonged intermittent fasting on the course of MS
in a cohort of patients who reside in Isfahan, Iran. The cohort
consisted of 40 adult MS patients who fasted during Rama-
dan and 40 MS patients who did not fast. Only patients with
mild disability (expanded disability status scale (EDSS) score
^3) were included. All patients were followed for 6 months
after Ramadan to assess their EDSS score changes and to re-
cord the number of clinical relapses. At the end of the study,
no significant changes in EDSS or the frequency of clinical
relapses were detected between the 2 groups (p 1 0.05).
Fasting had no short-term unfavorable effects on the dis-
ease course in MS patients with mild disability. However,
larger multi-center prospective studies of longer duration
are needed to validate the results of this study.
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Received: January 9, 2008
Accepted: September 16, 2008
Published online: January 29, 2009
Introduction
Sustained fasting is a characteristic of several of the
world’s great religions. One of the 5 fundamental rituals
in Islam, a religion professed by over 1 billion people, is
fasting during the month of Ramadan, which is obliga-
tory for all healthy Muslim adults [1, 2]. Adult Muslims
are required to abstain from taking any food, beverages
or oral drugs, smoking and sexual intercourse between
dawn and sunset. During the fasting month, many phys-
iological and biochemical changes occur that might be
due to alteration in eating and sleeping patterns [3]. In
healthy individuals, this kind of fasting may have no
harmful consequences on health [4]; however, few studies
have been performed to shed light on the effects of pro-
longed fasting in patients suffering from various diseases,
including multiple sclerosis (MS).
Fasting during Ramadan is an important occasion for
Muslims. It is a challenge for Muslim MS patients to de-
cide whether or not to fast as they do not know whether
prolonged abstinence from food and drink could have an
unfavorable impact on the course of their disease. Since
most people living in Iran are Muslims, they fast during
Ramadan. In addition, a high prevalence and incidence
of MS have been recently detected in Iran [5, 6]. As a re-
sult, Isfahan is a suitable area for studying the effects of
an environmental factor such as fasting on MS. This
study was performed to assess the impact of prolonged
fasting on the course of disease in an Iranian MS popula-
tion living in Isfahan, Iran.
Farzad Fatehi
Neurology Department and Medical Education Research Center
Isfahan University of Medical Sciences, Alzahra Hospital
Sofeh Street, Isfahan 81744 (Iran)
Tel. +98 91 3318 6330, Fax +98 311 668 4510, E-Mail fatehi@edc.mui.ac.ir
 Methods Table 1. Demographic features of MS patients who fasted during
Ramadan vs. MS patients who did not
Ramadan
The periods corresponding to Ramadan in the Gregorian cal- Characteristics Fasting Nonfasting p
endar are changeable since the holy month is determined by the patients patients value
lunar calendar, which, at 354 days, is 11–12 days shorter than the
solar one. Therefore, Ramadan moves forward 11 days each year Number of patients 40 40
and may be in any of the 4 seasons, making the number of fasting Mean age, years 28.7386.80 31.1089.09 >0.05
hours variable between 11 and 18. In our study, Ramadan oc- Mean disease duration, years 2.9881.26 3.0581.31 >0.05
curred during autumn of the year 2006, and the fasting period Mean number of relapses per
was around 13 h. year 0.7580.52 0.8980.79 >0.05
Sex >0.05
Study Area Female 26 25
This study was conducted in Isfahan, which is located in the Male 14 15
center of Iran. The estimated population of Isfahan province was Medications >0.05
4,559,256, based on the recently released 2006 national census No treatment 5 6
data. The residents of Isfahan are racially and culturally homog- Interferon 22 28
enous and more than 99% of the population are Muslim. There- Cytotoxic 9 5
fore, many MS patients in Isfahan desire to fast, and ask their Combination of interferon
physicians about the possibility of fasting during the month of and cytotoxic 4 1
Ramadan.

Patients
Patients with mild disability (expanded disability status scale
(EDSS) score ^3) were recruited from members of the Isfahan
MS society. This prospective study included 40 adult MS patients Table 2. EDSS and number of attacks at the start of study and 6
(aged 117 years) who fasted during Ramadan and 40 adult MS months later
patients who did not fast and who served as controls. All fasting
patients abstained from eating and drinking from 5 AM to 6 PM Fasting Nonfasting p
for 28 days. The 2 groups were matched for age, gender, EDSS and patients patients value
relapse rates before entering the study (table 1). Patients with con-
current diseases did not participate. Institutional ethical approv- Mean rank of previous number
al was obtained and all patients signed an informed consent be- of attacks at the start of study 38.11 42.89 >0.05
fore participation in the study. EDSS mean rank at the start of study 40.93 37.92 >0.05
EDSS mean rank at the end of study 41.55 39.45 >0.05
Statistical Analysis EDSS change mean rank 40.61 40.39 >0.05
All patients were followed for 6 months after Ramadan to as- Mean rank of number of attacks in
sess their EDSS score changes and to record the number of attacks 6 months 39.42 41.58 >0.05
they experienced. Since the distribution of variables was non-
parametric, Mann-Whitney test was used for comparison of the
data from the 2 groups. p ! 0.05 was regarded as significant.

0.05). At the end of study it was 0.63 8 0.50 in the fasting

Results
A total of 80 MS patients (40 in the fasting and 40 in
the nonfasting group) participated in this prospective
study and all finished it successfully. The demographic
and clinical characteristics of patients are presented in
table 1. In the fasting group, 5 patients each had a single
clinical relapse and in the nonfasting group 7 patients
experienced 8 relapses. The mean (8SD) number of at-
tacks in the fasting group was 0.13 8 0.35 versus 0.20 8
0.47 in the nonfasting group. The mean (8SD) EDSS
score at the start of study was 0.59 8 0.52 in the fasting
group versus 0.51 8 0.53 in the nonfasting group (p 1
group versus 0.58 8 0.51 in the nonfasting group. The
median number of attacks and EDSS changes was not
significantly different between the 2 groups when com-
pared 6 months after Ramadan (table 2).
Discussion
Iran has been considered to be a low-risk area for MS;
however, a study in 2006 demonstrated that the preva-
lence of MS was 43.8/100,000 [5]. Presently, Isfahan is
considered to be a medium-to-high risk area for MS [5,
6]. The unique demographic and cultural characteristics

The Effects of Fasting on Multiple Eur Neurol 2009;61:230–232 231

Sclerosis
of countries such as Iran that have an Islamic tradition
provide the opportunity to investigate issues, such as
fasting, which are not encountered in western societies.
Our results showed no significant differences between
the fasting and nonfasting cohorts in the number of clin-
ical relapses or EDSS score after 6 months. Since fasting
may exert metabolic and physiologic stress on MS pa-
tients and, theoretically, such stress may worsen the dis-
ease, the observed results may be explained by an increase
in antioxidant activity during fasting. There is accumu-
lating evidence to show that oxidative stress plays an im-
portant role in the pathogenesis of MS [7]. In MS lesions,
several markers for oxidative damage are present and, ad-
ditionally, reduced concentrations of antioxidants have
been measured in the sera of MS patients as well as in MS
plaques [8, 9]. Furthermore, prolonged intermittent fast-
ing during Ramadan may increase antioxidant activity.
This is because fasting restricts fat intake, which is asso-
ciated with a marked reduction in low-density lipopro-
tein levels [10]. Fat acts as an oxidant insult in the body;
high-fat meals impair macrovascular endothelial func-
tion and are also linked to increased oxidative stress [11].
The diminished food intake during Ramadan, especially
that of fats which further lowers low-density lipoprotein
levels, might increase antioxidant activity and conse-
quently could protect against relapses after the end of the
fasting month.
Another explanation for the observed effect may be a
linear increase in serum concentration of uric acid in in-
dividuals who fast during Ramadan [12]. A number of
studies have demonstrated that patients with MS have
low serum levels of uric acid [13]; therefore, elevated se-
rum uric acid levels during Ramadan may confer protec-
tion against MS relapse.
We did not include moderately or severely disabled pa-
tients (EDSS 13) because these patients ordinarily con-
sume multiple medications to alleviate their symptoms.
In addition, their disability does not let them fast for a
long period of time.
In conclusion, prolonged intermittent fasting may
have no negative short-term impact on MS patients with
mild disability. However, before making a decision to
fast, MS patients should consult their treating neurolo-
gists and all their circumstances should be taken into ac-
count. Larger prospective clinical studies of cohorts of
MS patients are needed to validate the findings of our
limited study and shed more light on the interactions be-
tween fasting and MS.

References

1 Sakr AH: Fasting in Islam. J Am Diet Assoc
1975;67:17–21.
2 Bener A, Galadari S, Gillett M, Osman N, Al-
Taneiji H, Al-Kuwaiti MHH, Al-Sabosy
MMA: Fasting during the holy month of Ra-
madan does not change the composition of
breast milk. Nutr Res 2001;21:859–864.
3 Aksungar FB, Eren A, Ure S, Teskin O, Ates
G: Effects of intermittent fasting on serum
lipid levels, coagulation status and plasma
homocysteine levels. Ann Nutr Metab 2005;
49:77–82.
4 Benaji B, Mounib N, Roky R, Aadil N, Houti
IE, Moussamih S, Maliki S, Gressier B, El
Ghomari H: Diabetes and Ramadan: review
of the literature. Diabetes Res Clin Pract
2006;73:117–125.
5 Saadatnia M, Etemadifar M, Maghzi AH:
Multiple sclerosis in Isfahan, Iran. Int Rev
Neurobiol 2007; 79:357–375.
6 Etemadifar M, Janghorbani M, Shayganne-
jad V, Ashtari F: Prevalence of multiple scle-
rosis in Isfahan, Iran. Neuroepidemiology
2006;27:39–44.
7 Liu Y, Zhu B, Wang X, Luo L, Li P, Paty DW,
Cynader MS: Bilirubin as a potent antioxi-
dant suppresses experimental autoimmune
encephalomyelitis: implications for the role
of oxidative stress in the development of
multiple sclerosis. J Neuroimmunol 2003;
139:27–35.
8 Gilgun-Sherki Y, Melamed E, Offen D: The
role of oxidative stress in the pathogenesis of
multiple sclerosis: the need for effective an-
tioxidant therapy. J Neurol 2004; 251: 261–
268.
9 van Meeteren ME, Hendriks JJA, Dijkstra
CD, van Tol EAF: Dietary compounds pre-
vent oxidative damage and nitric oxide pro-
duction by cells involved in demyelinating
disease. Biochem Pharmacol 2004; 67: 967–
975.
10 Qujeq D, Bijani K, Kalavi K, Mohiti J, Aliak-
barpour H: Effects of Ramadan fasting on
serum low-density and high-density lipo-
protein-cholesterol concentrations. Ann
Saudi Med 2002;22:297–299.
11 Catal F, Avci A, Karadag A, Alioglu B, Avci
Z: Oxidant and antioxidant status of Turkish
marasmic children: a single center study. J
Trace Elem Med Biol 2007; 21:108–112.
12 Gumaa KA, Mustafa KY, Mahmoud NA, Ga-
der AM: The effects of fasting in Ramadan.
1. Serum uric acid and lipid concentrations.
Br J Nutr 1978;40:573–581.
13 Mostert JP, Ramsaransing GS, Heersema DJ,
Heerings M, Wilczak N, De Keyser J: Serum
uric acid levels and leukocyte nitric oxide
production in multiple sclerosis patients out-
side relapses. J Neurol Sci 2005;231:41–44.

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