Religion rituals could affect the patients. This research sought the data of Ramadan fasting effects on Diabetes Mellitus patients in North Sumatra Province of Indonesia. In Indonesia, as a country in the tropics, the duration of fasting Ramadan is around 13.5-14 hours without eating and drinking during the fasting period. The provision of glucose for fasting people will change from 8-16 hours of absorption of food, so that people who are fasting will experience the process of gluconeo-genesis. During the month of Ramadan there will also be many changes in human activities such as diet, working hours and will add activities at night such as tarawih (night prayer) and tadarusan (Holy Quran Recital) which means increasing physical activity at night. Fasting itself is a worship that must be performed by every Muslim community, including people suffering from chronic diseases such as Diabetes Mellitus (DM). 

With changes in diet and religious activities in the form of physical activity by carrying out circumcision prayers in the month of Ramadan, it will cause changes in the physiology of the human body during fasting [1-4]. Some forms of changes in body physiology that may occur are related to with metabolic processes such as changes in blood parameters, lipid profiles, hs-CRP, leptin, ghrelin, albumin and others in fasting people [1-6].

This study sought the effect of Ramadan fasting on the body mass index of type 2 DM patients in Medan. The objectives of this study were: Daily Blood Sugar Control (DBSC), 2PP, body weight, BMI and waist circumference in type 2 DM patients in Medan.   

This type of research is a longitudinal/experimental prospective study, with a sample size of 19 respondents and the study population was DM patients in Medan, 

Inclusion Criteria

• Diabetes Patients with type 2 who have been diagnosed, Muslim and willing to perform Ramadan fasting for a month

• Patients with type 2 diabetes without complications (controlled)

Exclusion Criteria

DM patients with complications. Data collection was done as follows: 

• All subjects were asked for consent to participate in the study by filling out and signing the informed consent form

• Samples identity included name, age, gender, body weight (BW) and height (H) and measuring BMI and waist circumference. Blood samples were taken one week before fasting and one week before Eid, for examination

Basic Characteristics of Respondents were 19 patients with type 2 diabetes who had met the inclusion criteria. A total of 13 respondents (68.4%) were male with a mean age of 57.26 years. From the results of blood pressure measurements obtained a mean systolic blood pressure of 136.62 mmHg and a diastolic blood pressure of 86.58 mmHg. The mean height of the respondents was 156.74 cm. Generally, respondents (89.5%) performed tarawih regularly and 13 respondents (68.4%) prayed 23 cycles of tarawih. The majority of respondents carried out tadarus as many as 17 people (89.5%) (Table 1).

Table 1: Basic Characteristics of Respondents

Weight and DBSC and WS; BMI Before and After Ramadan Fasting

The average body weight before fasting was 66.21 kg, while after fasting it decreased to 64 kg. By using the T dependent test, there was a significant difference in the mean between before and after fasting (p <0.001). see Table 2. Meanwhile, the mean DBSC before fasting was 122.89 mg/dL and after fasting it decreased to 117.89 mg/dL. However, using the Wilcoxon test, there was no significant difference in the mean between the two measurements (p = 0.432). see Figure 1. Thus, the Blood Sugar Level value of 2PP before fasting was 177.11 mg/dL and after fasting it decreased to 171.63 mg/dL. By using the Wilcoxon test, a significant difference in the mean of the two measurements was found (p = 0.039). see Figure 2. The mean baseline BMI score of 26.86 and the end of 25.96, with the Wilcoxon test showed a statistically significant difference between BMI before and after fasting with p value <0.05. The mean value of initial waist size was 91.26 and at the end of 90.74, with the T-test showed a statistically significant difference between waist size before and after fasting with p value <0.05. Figure 3. Figure 4. Figure 5.

Table 2: Body Weight and Blood Sugar Control (KGD) at the Beginning and at The End of Ramadan Fasting

Figure 1:               Boxplot Graph of Weight Difference Between Before and After Fasting

Figure 2: Boxplot Graph of DBSC Difference Between Before and After Fasting

Figure 3: Boxplot Graph The KGD2PP Difference Between Before and After Fasting

Figure 4: Boxplot Graph of BMI Difference between Before and After Fasting

Figure 5: Boxplot Graph of Difference in LP between Before and After Fasting

The relationship between body weight, body mass index and waist circumference with Ramadan fasting. 

Weight loss, BMI and Waist Size (WS) are widely associated with diet programs or restricting calorie intake, including fasting. below will explain the impact on body weight, BMI and waist circumference and will be discussed separately.

Weight

The results of this study indicate that in univariate ways, the overall sample data shows a varying decrease from 1-5 kg ​​with an average decrease of 2.21 kg. In the bivariate test with the mean difference test (T-Test), it was found that fasting had a significant effect on weight loss (p <0.001. This result is in line with the explanation from Azizi [1], which states that there is an effect of fasting on weight loss in his writing with the title "Islamic Fasting and health". This can be explained by doing fasting, there will be a reduction in carbohydrate intake and then followed by the mobilization of luscious to produce energy for activities so that it affects body weight.

Body Mass Index (BMI)

The results of this study showed that in univariate way the overall sample data showed a decrease in BMI. Initial BMI 26.86±5.10 and final BMI 25.96±5.18. and after being tested with the Wilcoxon Union, there was a significant difference in value (p <0.05). This result is in line with the explanation by Mazidi [7], who stated that the effect of fasting on weight loss and MBI in his writing entitled "Effects of Ramadan Fasting on a lipid profile: A Narrative Review". This can be explained by doing fasting, there will be a reduction in carbohydrate intake and then it will be followed by the mobilization of luscious to produce energy for activities so that it affects body weight. The existence of a direct influence on body weight will also affect the body mass index.

Waist Size (WS)

The results of the mean value of initial waist circumference 91.26 and 90.74 at the end, with the T-test test showed a statistically significant difference between LP before and after fasting with p value <0.05.

In a study conducted by Saleh [8], with a sample size of 60, where the sample also undergoes a month of fasting, there is a difference in values. In the male sample obtained waist circumference values ​​at the beginning of fasting (94.68±11.01) and at the end of fasting 92.00±10.70.29 This weight loss is due to the efficient utilization of body fat during fasting. These results have also been reported that fasting people who are overweight lose more than normal weight than normal weight people during the fasting month of Ramadan. 

Obesity has been recognized as a serious risk factor for mortality and morbidity of cardiovascular disease in the general population as well as in sufferer’s diabetes mellitus. Hence the reduction in waist circumference observed in this study during 4 weeks of fasting may translate into significant health benefits for those who fast [8].

DBSC, BSL 2PP with Ramadan fasting

Fasting Blood Sugar Levels

From the univariate results of fasting blood sugar levels, it can be seen from each sample that 12 people experienced an increase, 1 person had a fixed value and 6 people experienced a decrease, but in total, it was found that there was a tendency to decrease fasting blood sugar levels at the end of fasting. The DBSC value before fasting was 122.89 mg / dL and after fasting it decreased to 117.89 mg/dL. However, using the Wilcoxon test, there was no significant difference in the mean between the two measurements (p = 0.432). Previous research conducted by Saleh [8], on a sample of 60 people also showed that there was no significant mean value of fasting blood sugar levels at the time of fasting and the end of fasting in Ramadan (early fasting 5.55±0.58mmol, end of fasting 5.55±0.55mmol). Other studies conducted by Laajam 1990, Salman 1992 and Dehghan 1994 obtained the same results [9-11]. This may be due to various differences in the food consumed during fasting both in the amount and type of food eaten as well as differences in body metabolism. Besides that, the bias is also caused by the drugs that the research subjects are taking [12].

Fasting Blood Sugar Levels 2 hours

The BSL value of 2PP before fasting was 177.11 mg/dL and after fasting it decreased to 171.63 mg/dL. By using the Wilcoxon test, a significant difference in the mean of the two measurements was found (p = 0.039). This is probably due to the recent absorption state of the glucose turnover rate of 2 mg / kg / min. In normal adults, a slight decrease in serum glucose of between 3.3 and 3.9 mmol/l (60-70 mg/dL) occurs within hours of fasting; decrease in serum glucose but stops due to breakdown of glycogen and a decrease in both glycogen synthesis and glycolysis in the liver. These changes are the result of decreased insulin and increased glucagon and sympathetic activity. In the early stages of the post-absorption period, decreased glucose is associated with depletion in hepatic glycogen stores [13].

Limitations

The research has limitations including: 

• The sample is small so that it may not be able to reflect the actual results

• The activities and diet of the sample patients cannot be uniformed so that it can interfere with the results of the measurements taken

Data interpretation shows two conclusions: 

• Fasting does not cause a significant decrease in Fasting Blood Sugar Levels (DBSC)

• Fasting causes a decrease in body weight (BW), waist size (WS), body mass index (BMI)

Suggestion

DM patients who are fasting are expected to reduce their consumption of food in the form of fried or high fat foods, in order to improve the lipid profile which can help prevent cardiovascular complications. To other researchers, it is expected to be able to verify the results of this study with research with a larger number of samples. Institutions can take advantage of the results of this study as material for assessment and research development related to the effect of fasting on the endocrine system.

1. Azizi, F. “Islamic fasting and health.” Annals of Nutrition and Metabolism, vol. 56, 2010, pp. 273–282.

2. Jaleel, M.A. et al. “Ramadan and diabetes: As-Saum (The fasting).” Indian Journal of Endocrinology and Metabolism, vol. 15, no. 4, 2011, pp. 268–273.

3. Azizi, F. and B. Siahkolah. “Ramadan fasting and diabetes mellitus.” International Journal of Ramadan Fasting Research, vol. 2, 1998, pp. 8–17.

4. Azizi, F. “Research in Islamic fasting and health.” Annals of Saudi Medicine, vol. 22, 2002, pp. 186–191.

5. Kamal, S. et al. “Effect of Islamic Fasting on lipid profile, total protein and albumin in healthy Muslim male subjects of Shri ram Murti Smarak institute of medical sciences, Bareilly, Uttar Pradesh.” National Journal of Medical Research, vol. 2, no. 4, 2012, pp. 407–410.

6. Alzoghaibi, M.A. et al. “Diurnal intermittent fasting during Ramadan: The effects on leptin and ghrelin levels.” PLoS One, vol. 9, no. 3, 2014, pp. 1–7.

7. Mazidi, M. et al. “Effects of Ramadan fasting on lipid profile: A narrative review.” Journal of Fasting and Health, vol. 2, no. 2, 2014, pp. 57–61.

8. Saleh, S.A. et al. “Effects of Ramadan fasting on waist circumference, blood pressure, lipid profile and blood sugar in a sample of healthy Kuwaiti men and women.” Malaysian Journal of Nutrition, vol. 11, no. 2, 2005, pp. 143–150.

9. Laajam, M.A. “Ramadan fasting and non-insulin-dependent diabetes: Effect on metabolic control.” East African Medical Journal, vol. 67, 1990, pp. 732–736.

10. Salman, H. et al. “Ramadan fasting in diabetic children in Riyadh.” Diabetic Medicine, vol. 9, 1992, pp. 583–584.

11. Dehghan, M.R. et al. “The Effect of Ramadan Fasting on Blood Glucose and Lipids in Type 2 Diabetics.” Journal of the Faculty of Medicine, SBUMS, vol. 18, 1994, pp. 42–47.

12. Elnasri, H.A. and A.M. Ahmed. “Effects of Ramadan fasting on blood levels of glucose, triglyceride and cholesterol among type II diabetic patients.” Sudanese Journal of Public Health, vol. 1, no. 3, 2006, pp. 203–206.

13. Heber, D. “Starvation and nutrition therapy.” Endocrinology, edited by L.J. DeGroot and J.L. Jameson, 4th ed., Saunders, 2001, vol. 1, pp. 642–645.