ORIGINAL ARTICLE

Effects of Intermittent Fasting on Weight Loss in Asian Indian

Adults with Obesity
Sheryl Salis1, Syed Shefa2, Nitika Sharma3, Natasha Vora4, Ranjit Mohan Anjana5, Viswanathan Mohan6, Harish Ranjani7*
Received: 25 January 2022; Accepted: 25 July 2022

A b s t r ac t as a popular dietary strategy for weight

loss and has been termed as intermittent
Background: Worldwide, obesity has nearly tripled since 1975 and has become a major healthcare
challenge today. Intermittent fasting (IF) is gaining popularity as a weight loss strategy in recent fasting. This study aimed to understand
times. This study aimed to study the role of IF as a modern-day weight-loss strategy in obese adults the application of IF as a modern-day
through a real-world pilot experiment conducted at a nutrition clinic in Mumbai. weight-loss strategy through a real-world
Methodology: To understand the effects of IF on weight loss, 32 overweight/obese [body mass pilot experiment conducted at a nutrition
index (BMI) ≥23 kg/m2] adults from a nutrition clinic in Mumbai, were assigned consecutively to an clinic in Mumbai.
IF plan and followed up for 3 months. Their demographic, anthropometric, and dietary assessments
were done pre- and post-intervention. Qualitative interviews were done at the end of the study M e t h o d o lo g y
to record the participants’ overall well-being, experience, and sustainability of IF.
Results: 56% of study participants were males and their mean age was 35.6 ± 8.9 years. 65.6% Recruitment of the Participants
of participants were able to maintain 14–16 hours of fasting and 53% managed all 7 days of IF. and Eligibility Criteria
Analysis of post-intervention data showed a significant reduction in mean body weight (88.5 ± An experimental study was conducted in a
19 to 83.8 ± 17.6 kg), waist circumference (M: 108.2 ± 11.3 to 103.6 ± 4.4 cm, F: 98.9 ± 8.8 to 93.3 clinic located in Mumbai, India. Real-world
± 3.3 cm), BMI (31.4 ± 5.3 to 29.6 ± 5.1 kg/m2), daily calories (1782 ± 237 to 1388 ± 243 kcal/day), clinic data was used to understand
carbohydrate intake (267 ± 18.4 to 164 ± 4.0 g/day), and an increase in protein intake (39 ± 11 to the effects of IF on weight loss. Using a
55 ± 11 g/day). Participants reported positive experiences of practicing IF such as improved fitness,
purposive sampling technique, 32 adult
sleep cycle, and adoption of healthy eating habits.
individuals both males and females, who were
Conclusion: The study demonstrates that IF could aid in weight loss and adoption of a healthier
overweight or obese (BMI ≥23 kg/m2) and
lifestyle.
were consecutively assigned IF as a weight-loss
Journal of the Association of Physicians of India (2022): 10.5005/japi-11001-0098 strategy in January 2021, were included as the
study participants. Pregnant and lactating
women and known cases of prediabetes and
Introduction carbohydrate diet, ketogenic diet, meal
diabetes mellitus were excluded from this study.
replacement therapy, and IF are gaining a
T he current obesity epidemic is
overwhelming in terms of its magnitude
and public health impact. Worldwide, obesity
lot of popularity. The current guidelines for
the management of obesity are continuous
Study Design and Protocol
All the participants were briefed regarding the
energy restriction (CER) along with lifestyle
has nearly tripled since 1975.1 Globally, the details of the study. A unique identification
inter vention and behavioral change.
prevalence of overweight individuals was number was created for them and informed
However, this method yields modest weight
found to be 39% in adults aged 18 years consent was taken. Baseline screening
loss and is not sustainable for long periods of
and above, and 13% of adults were found comprised in - person inter views and
time.4 There has been an increased interest in
to be obese as per the World Health counseling. Additionally, the following data
identifying other dietary strategies for weight
Organization report 2016.1 According to the
loss which involve restricting energy intake to
Indian Council of Medical Research-India
certain periods of the day or prolonging the
Diabetes (ICMR-INDIAB) study, the prevalence 1
Registered Dietitian and Certified Diabetes
fasting interval between meals.
of obesity in adults (aged ≥20 years) in India Educator, Founder, and Director; 2Senior
Intermittent fasting refers to a period
was found to be 41.7% in women and 22.3% Nutritionist and Certified Diabetes Educator,
of fasting up to 16 hours daily, or a 24-hour Nurture Health Solutions, Mumbai,
in men.2
fast on alternate days, or a complete 24-hour Maharashtra; 3Research Assistant, Department
Obesity Medicine Association defines
fast twice a week on non-consecutive of Translational Research, Madras Diabetes
obesity as a “chronic, relapsing, multi-factorial,
days. Thus, a fasting period anywhere Research Foundation, Chennai, Tamil Nadu;
neurobehavioral disease, wherein an 4
Senior Nutritionist and Certified Diabetes
between 12–20 hours can be referred to as
increase in body fat promotes adipose tissue Educator, Nurture Health Solutions, Mumbai,
IF. Accordingly, for each fasting cycle, the
dysfunction, resulting in adverse metabolic, Maharashtra; 5Vice President; 6President,
remaining hours will be considered the
biomechanical, and psychosocial health Madras Diabetes Research Foundation;
feeding period. Recent studies have shown 7
Senior Scientist and Head, Department of
consequences.” Obesity is the main risk
substantial weight loss and fat loss with IF.5 Translational Research, Madras Diabetes
factor for non-communicable diseases like
Fasting is a ubiquitous religio-cultural Research Foundation, Chennai, Tamil Nadu,
type 2 diabetes, hypertension, stroke, heart India; *Corresponding Author
practice found, in various forms, across the
disease, osteoarthritis, obstructive sleep
world. Fasting is an integral part of many How to cite this article: Salis S, Shefa S,
apnea, and certain types of cancers.3
religions in India and worldwide.6 However, Sharma N, et al. Effects of Intermittent
The most commonly used intervention Fasting on Weight Loss in Asian Indian
during the last decade, especially among the
for weight loss is calorie restriction; however, Adults with Obesity. J Assoc Physicians
young and middle age groups, the traditional
recently, dietary interventions like low India 2022;70(9):62–66.
fasting practice has now regained attention

© The Author(s). 2022 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (https://creativecommons.org/licenses/
by-nc/4.0/). Please refer to the link for more details.

were recorded during this visit by a qualified
and trained dietitian:
• Demographic characteristics: Name,
age, gender, address, education, and
occupation.
• Anthropometry: Height, weight, BMI, and
waist circumference.
• Dietar y assessment: Food habits—
vegetarian or nonvegetarian/vegan/
lacto veg, etc., food allergies, and 24-hour
dietary recall.
Height
Height measurement was carried out with
the help of a stadiometer. Participants were
asked to remove shoes and stand upright
with their back against the scale, keep heels
together, and eyes directed forward. Height
was measured to the nearest centimeter.
Weight
Weight was measured to the nearest 0.1 kg
using a standard weighing scale (Omron Karada
Scan Body Composition Monitor HBF-375,
China) which was kept on a firm horizontal
surface. This was compared to their home
weighing scale. To obtain the most valid
and reliable measurement, participants
were encouraged to weigh first thing in the
morning on an empty stomach and after
emptying their bladder/bowels.
Body Mass Index
The BMI was calculated using the formula
weight (kg) divided by height square (m2).
Waist Circumference (WC)
Waist circumference was measured in
centimeters using a non-stretchable fiber
measure tape. The participants were asked to
stand erect in a relaxed position with both feet
together. One layer of clothing was accepted.
Waist girth was measured as the smallest
horizontal girth between the coastal margins
and the iliac crests at minimal respiration.
Body Fat and Visceral Fat Percent (%)
Omron Karada Scan Body Composition
Monitor HBF-375 was used to measure body
fat and visceral fat levels. The participants
were requested to follow the below steps
before body composition analysis.
• Maintain adequate fluid intake the day
before and on the day of assessment.
• Stand upright for at least 5 minutes.
• Remove socks and heavy accessories like
jewelry, watches, and jackets.
• Use the restroom before analysis.
• Not to eat or exercise for at least 3 hours.
Effects of Intermittent Fasting on Weight Loss
• Not to consume alcohol or excess caffeine compared using a Student’s t-test. The mean
for at least 24 hours. of three values (collected at first, second,
• Not to use lotion or ointment on hands and third follow-up) was taken as the final
and feet. post-intervention value for the composite
pre-post analysis. Differences in parameters
Par ticipants followed 12–16 hours of
studied are presented as means and standard
fasting with 12–8 hours of feeding period
deviation (SD) and percent change. The
for 3 months. Participants were followed
formula used to calculate percent change
up every month for 3 months. Due to the
was: [(mean at post-intervention – mean at
COVID -19 pandemic second wave, the
baseline)/(mean at baseline)] × 100.
in-clinic anthropometric measurements were
The key informant interviews were
not possible post-intervention. Therefore,
audio-recorded and transcribed verbatim
participants were requested to send pictures
manually. The transcripts were analyzed
of their weight and waist circumference
alongside the audio recording to ensure
measures on WhatsApp or email. In addition
accurate transcriptions such that meaning
to data collected at baseline, information on
was not lost. Content analysis was used
duration and frequency of fasting, challenges,
to identify the barriers, facilitators, and
and personal experiences were also recorded,
acceptability of the intervention. Coding of
post-intervention.
important categories and sub-categories was
A qualitative assessment was done at the
made and, finally, thematic conclusions were
end of the study; which included questions
drawn in consensus using an ethnographical
on the overall well-being, experience, and
methodology and further interpreted.7
sustainability of IF. As in-person interviews
The pilot study was approved by the
were not possible due to COVID-19, telephonic
Madras Diabetes Research Foundation
interviews were conducted after participant
Institutional Ethics Committee (Ref. No.:
consent was recorded.
ECR/194/Inst/TN/2013).
Qualitative Study
Key informant interviews were conducted R e s u lts
online to assess barriers, facilitators, and A total of 32 participants were recruited for the
acceptability of IF. Interviews were conductedstudy and 56% of participants were males. The
by a moderator and an observer who were mean age, weight, and BMI of the participants
trained to conduct key informant interviews. were 35.6 ± 8.9 years, 88.5 ±19 kg, and 31.4 ±
The study team first prepared an interview 5.4 kg/m2, respectively (Table 1). The major
guide that broadly listed the questions health issue reported by the participants were
relevant to the study aim. The moderator hyperuricemia, polycystic ovarian syndrome
conducted the interviews with participants (PCOS), fatty liver, and bloating. The mean
while the observer took notes. The interviews calorie, protein, and carbohydrate intake was
were conducted in a language familiar to 1782 ± 237 kcal/day, 39 ± 11 g/day, and 267 ±
participants (English or Hindi). The interview18.4 g/day at baseline, respectively.
began with taking the verbal consent of Post-intervention, 46.9% of participants
the participant for the interview as well as reported that they faced challenges while
for the audio recording with the assurance following IF. 40.6% managed to cook their
to use only anonymized quotes in research food and for 59.4% of the participants, their
publications. This was followed by asking wife/mother helped in managing cooking
open-ended questions using the interview to follow the IF diet (Table 2A). 37.5% of
guide. When there was a lull or a pause in theparticipants followed a fasting cycle for
conversation, the moderator used probes to 14 hours, followed by 28.1% and 18.8% who
stimulate discussion. Each interview lasted followed the fasting cycle for 16 and 12 hours,
for about 10–15 minutes and thereafter, the respectively. 65.6% of participants were able
tapes were cross-checked for completeness. to maintain 14–16 hours of fasting and 53%
The recordings were transferred to the laptop,managed all 7 days of IF, followed by 25%
transcribed, and analyzed for themes. and 18.8% who followed the IF regimen for
5 and 6 days, respectively. More than half of
Statistical Analysis the participants (53.1%) influenced others to
T he analysis was conduc te d in SPSS follow IF. Analysis of data post-intervention
version 16.0. The effect of IF on weight loss (Table 2B) showed a significant reduction
was assessed by evaluating the changes in in mean weight, waist circumference, BMI,
anthropometric measurements at baseline calorie intake, and increase in protein intake.
and post-intervention. Changes in mean Body fat % and visceral fat % showed a
values of weight, waist circumference, clinically relevant reduction though it was
BMI, body fat %, and visceral fat % were not statistically significant possibly due to the
Journal of the Association of Physicians of India, Volume 70 Issue 9 (September 2022) 63
 Effects of Intermittent Fasting on Weight Loss

Table 1: Baseline characteristics of the participants smaller numbers. Participants also reported a
Socio-demography (N = 32) reduction in bloating and regularity in their
Gender (male), n (%) 18 (56) monthly cycles. The challenges and positive
Age (years), mean ± SD 35.6 ± 8.9 experiences of the participants were further
Anthropometric measurements (mean ± SD) explored through the qualitative interviews
Height (cm) 167.4 ± 8.5 (Table 3).
Baseline weight (kg) 88.5 ± 19 As seen in Figures 1A and B, all participants
Baseline BMI (kg/m2) 31.4 ± 5.4 reduced weight and waist circumference
Baseline WC (cm) steadily over the intervention follow-up
Male (n = 9) 108.2 ± 11.3 period with female participants showing a
Female (n = 10) 98.9 ± 8.8 higher drop in waist circumference compared
Body fat % 42.1 ± 5.9 to their male counterparts.
Visceral fat % 23.8 ± 6.0 Twelve participants participated in
Health Issues reported at baseline [n (%)] key informant interviews and based on
Hyperuricemia (>6.0 mg/dL) 1 (3.1) the data obtained during this process the
PCOS 3 (9.4) conversations were transcribed and extracted
Fatty liver 1 (3.1) to arrive at the following major five prominent
Bloating 2 (6.3)
themes (Table 3):
Participants on any kind of medication—yes (hypertension, 2 (6.3)
hypothyroidism, and uric acid) • Diet and physical activity routine before
General questions following IF/awareness about IF.
Eating habits nonvegetarian, n (%) 21 (65.6) • Positive experience with IF.
Baseline calorie intake (kcal/day), Mean ± SD 1782 ± 237 • Challenges faced while practicing IF.
Baseline protein intake (g/day), mean ± SD 39 ± 11.2 • Changes made in lifestyle after following IF.
Table 2A: General information on IF • Inf luencing others by sharing their
experiences about IF.
Questions N = 32, n (%)
No. of participants who faced challenges following IF 15 (46.9) Most of the participants could overcome the
Person who helped in managing cooking to follow IF diet challenges of fasting for long periods once
they realized how it helped reduce weight
Self 13 (40.6)
Wife/mother 19 (59.4) and improve their sleep cycle. Participants
No. of participants who influenced others to follow IF 17 (53.1) also made important lifestyle changes
No. of hours participants followed IF, median 14 like being active, feeling energetic, doing
Fasting time (hours) regular exercise, managing portion sizes, and
12 6 (18.8) becoming conscious about healthy foods.
13 3 (9.4)
14 12 (37.5)
15 1 (3.1)
Discussion
16 9 (28.1) From this real-world pilot study, we report that
17 1 (3.1) IF helped to reduce weight, BMI, and waist
No. of days IF followed/week, median 7 circumference in Asian Indian adults with
Number of days IF followed/week obesity. Participants could maintain 14–16 hours
3 1 (3.1) of fasting for 5–7 days/week during a 3-month
5 8 (25.0) period with a lasting feeling of well-being. IF
6 6 (18.8) has slowly and steadily garnered attention as
7 17 (53.1) a modern-day weight-loss strategy.8 Pannen
et al. recently published a 2-year follow-up data
Table 2B: Mean change in anthropometric measurements and calorie and protein intake at post- from a randomized controlled trial using IF
intervention
and CER. The results indicated that IF and CER
N = 32 Baseline Post-intervention were equivalent in achieving weight loss over
Parameter Mean ± SD Mean ± SD 2 years while affecting dietary composition
Weight (kg) 88.5 ± 18.7 83.8 ± 17.6* comparably.9 While there is evidence on IF
Waist circumference (cm)
regimens producing equivalent weight loss as
compared to CER,7 some studies found greater
Male 108.2 ± 11.3 103.6 ± 4.4*
weight and/or fat loss and improvement in
Female 98.9 ± 8.8 93.3 ± 3.3*
metabolic profile with IF than with CER.
BMI (kg/m2) 31.4 ± 5.3 29.6 ± 5.1*
The most widely studied regimens of IF
Calorie intake (kcal/day) 1782 ± 237 1388 ± 243*
are the 5:2 type (fasting 2 days each week),
Protein intake (g/day) 39 ± 11 55 ± 11* alternate-day fasting, and time-restricted
Carbohydrate intake (g/day) 267 ± 18.4 164 ± 4.0* feeding (allows individuals to consume ad
Body fat % (N = 5) 42 ± 6 38 ± 5 libitum energy intake within specific windows,
Visceral fat % (N = 5) 24 ± 6.0 19 ± 6.1 which induces fasting periods on a routine
*p < 0.05 basis).10 All-day extreme caloric restrictions are

64 Journal of the Association of Physicians of India, Volume 70 Issue 9 (September 2022)


Figs 1A and B: Percent change in weight and waist circumference at different follow-up stages compared to baseline (A) percentage change in weight
(kg); (B) Percentage change in waist circumference (cm). #Total intervention period = 3 months
Table 3: Emergent themes from the participant key informant interviews
Theme
Diet and physical activity
routine before following
IF/awareness about IF
Positive experience with IF
Challenges faced while
practicing IF
Changes made in lifestyle
after following IF
Influencing others by
sharing their experience
about IF
Effects of Intermittent Fasting on Weight Loss
Outcome
Most of them reported that they did not follow All the participants had an irregular diet and physical activity
any specific diet and physical activity routine routine, mainly due to insufficient time and lack of awareness
before starting with IF. Few participants had
tried some specific diets. These included mono
diets, two meal plans, and a normal weight
loss diet
All the participants reported that they felt
comfortable with IF after following it for some
time except for one. Participants felt that they
were following healthy eating habits. Also, IF
helped them in resolving health issues like
bloating and irregular periods
Challenges faced by participants while
practicing IF included midnight starvation,
cravings, weakness in the morning, difficulty
cooking specific meals, gastric issues,
disturbed bowel movements, and difficulty
sustaining if one is socially very active and
attends parties
Lifestyle changes brought in by IF included
being active, regular exercise, managing
portion sizes, having light and early dinner,
no snacking postdinner, having fewer
carbohydrates in the diet, awareness about
health, and consciousness about healthy foods
Participants reported mixed responses for
influencing others. More than half of the
participants shared their experience with IF
and exercise schedule with others
Journal of the Association of Physicians of India, Volume 70 Issue 9 (September 2022)
Interpretation
Participants felt that IF helped them reduce weight and improve
their sleep cycle. As a result, they felt light, active, fit, and happy
Participant A, aged 42 years, male, said that “I challenged myself for
21 days because if you follow anything for 21 days then it becomes
a habit”
Participant B, aged 30 years, male, said that “I feel nice when people
tell me that I have become lean”
Participant C, aged 29 years, female said that “It is a way of mindful
eating. I manage my time properly. All meals are preplanned. My life
is systematic now”
Most of the participants had overcome the challenges faced while
practicing IF as they got used to it over a period of time
Participant D, aged 39 years, female, reported that one-pot meals
suggested by my dietitian helped me manage early dinners with
ease and helped me achieve my nutritional requirements
Participant E, aged 24 years, male, said that “I drink green tea to
fight my cravings and it is not so difficult anymore”
Participant F, aged 45 years, male, said “it is more of a mindset. Once
you are into it, it is easy to follow”
Lifestyle changes were very well accepted by all. It motivated
participants to eat healthy food in limited portions and be
physically active
Participant G, aged 38 years, female, said that “Now I eat good
breakfast, moderate lunch, and light dinner. I feel very light as food
is digested before I hit the bed at night”
A few participants felt that they could continue IF for their life and
tried to influence others as well
Participant H, aged 38 years, female, said “I recommend it to most
of the people I meet, as I feel it is a healthy eating habit rather than
losing weight”
Participant F, aged 45 years, male, said “I tell people about IF but the
intent to follow it has to be very strong”
65

associated with hunger and irritability, making
it difficult to implement. Restricting food
intake to a time window of 8–10 hours or less
daily seems to be a more feasible alternative
as also seen in our study. Participants in this
study showed a significant weight loss post-IF
at 12 weeks with a mean calorie intake of
1388 kcal. Similar results have been reported
in various other studies.11,12 Some studies
conducted using IF have shown a reduction
in oxidative stress in addition to the reduction
in abdominal adipose tissue.13,14
Abdominal obesity is associated with an
increased risk of type 2 diabetes, cardiovascular
disease, certain cancers, and all-cause
mortality. Hence, a reduction in abdominal
obesity has been shown to reduce the risk of
cardiometabolic diseases. Many studies have
found a reduction in waist circumference (an
indicator of abdominal obesity) with IF.15,16 Our
study showed similar results. Thus, IF can be
considered to be an effective dietary strategy
to lose weight and improve metabolic health
for people who can successfully adhere to a
restricted feeding window.
Evidence has shown that increased meal
frequency with excess calorie consumption
causes expansion of adipose tissue due to the
rise in plasma triacylglycerol concentrations
which remain high even after 6 hours of meal
consumption. IF involves compressing the
feeding window, thereby helping to reduce
the meal frequency and calorie consumption
which is imperative for weight loss.17
The optimal time window of 16:8 fasting
to feeding ratio is the most popular.18 In
our study, more participants (n = 12) were
comfortable with the 14:10 ratio, followed
by 16:8 (n = 9). Macronutrient composition and
quality of nutrients, reducing carbohydrates,
and increasing protein intake have been
shown to be beneficial in achieving weight
loss.19 In this study, increasing the protein
intake while reducing the carbohydrate and
calorie consumption during the feeding
window has facilitated weight loss. Other
studies have also shown similar findings. 20,21
For sustained weight loss, it is essential to
follow a diet that creates a negative energy
balance and focuses on good quality nutrients.
In order to optimize the beneficial effects of IF,
while offering optimum nutrition, individuals
should be cognizant of what they eat during
the feeding period and also maintain a regular
exercise routine. It has also been shown that
adherence to the meal plan and behavioral
modification is what finally predicts its
success.22 Our study shows the same results.
Over the last few decades, an eating pattern
consisting of three main meals and 2–3 times
snacking has become so engrained in our
culture that it makes IF difficult to implement in
66 Journal of the Association of Physicians of India, Volume 70 Issue 9 (September 2022)
Effects of Intermittent Fasting on Weight Loss
the real world. Participants in other studies have
reported hunger, irritability, and a decreased
ability to concentrate during periods of fasting
when they start on the IF regimen. However,
these side effects are known to disappear within
a month. It is thus important to make individuals
embarking on IF aware of these issues and keep
them motivated during this period.20
In our study, participants’ experience and
their adherence to the meal plan have been
encouraging. Though, 46.9% of participants
post-intervention reported facing challenges
in following IF, with constant encouragement,
they overcame their barriers and more than
half of the participants found it easy to
comply, and they even influenced their friends
and family to follow IF.
Strengths and Limitations
This is one of the first studies reported from
India on the effects of IF on weight loss.
Limitations of our study include small
sample size, lack of control group, lack of data on
biomarkers, and self-reporting of parameters
by the participants in the post-intervention
period because of the COVID-19 pandemic.
We need more data on long-term compliance,
sustainability, and metabolic effects, post-IF.
More studies are also needed on the effects
of IF in those with pre-diabetes and type
2 diabetes mellitus by conducting large-scale
multicentric randomized control trials.
C o n c lu s i o n s
This real-world pilot study is aligned with
the limited evidence available globally that
supports the use of IF as a weight loss strategy
in Asian Indian adults with obesity. However,
one following IF needs to consult a qualified
dietitian/nutritionist to ensure that their
nutritional requirements are being met and to
receive counseling and motivation to achieve the
desired results. The following individuals must
refrain from practicing IF: pregnant and lactating
women, and anyone with eating disorders or an
immuno-compromised condition. Individuals
with any medical condition or those with
diabetes on insulin therapy or oral hypoglycemic
agents must seek consent from their treating
physician, before embarking on IF.
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