Ramadan fasting alters endocrine and ... - Science Direct

Life Sciences 68 (2001) 1607–1615

Ramadan fasting alters endocrine and neuroendocrine circadian patterns. Meal–time as a synchronizer in humans? André Bogdana, Belal Boucharebb, Yvan Touitoua,* a

Laboratoire de Biochimie, Faculté de Médecine Pitié-Salpétrière 91 boulevard de l’Hôpital, 75013, Paris, France b Laboratoire d’Hormonologie, Hôpital Militaire Universitaire, Oran, Algeria Received 2 June 2000; accepted 17 August 2000

Abstract Muslims must refrain from eating, drinking, smoking, and sexual relations from sunrise to sunset during the month of Ramadan. Serum concentrations of melatonin, steroid hormones (cortisol, testosterone), pituitary hormones (prolactin, LH, FSH, GH, TSH) and thyroid hormones (free thyroxin and free triiodothyronine) were documented around the clock at six 4-hourly intervals before Ramadan began and on the twenty-third day of Ramadan (daytime fasting). Time series were analysed with repeated measures ANOVA. Statistically significant differences were found in some variables: the nocturnal peak of melatonin was diminished and may have been delayed; there was a shift in the onset of cortisol and testosterone secretion; the evening peak of prolactin was enhanced, FSH and GH rhythmic patterns were affected little or not at all by Ramadan fasting and only the serum TSH rhythm was blunted over the test time span. These data show that daytime fasting, modifications in sleep schedule and psychological and social habits during Ramadan induce changes in the rhythmic pattern of a number of hormonal variables. © 2001 Elsevier Science Inc. All rights reserved. Keywords: Rhythms; Synchronizers; Hormones; Fasting; Ramadan

Introduction One of the most important rules of Islam is that any healthy adult Muslim must refrain from eating, drinking, smoking, and sexual relations from sunrise to sunset during the month of Ramadan, the ninth month of the Muslim calendar. Since this is a lunar calendar, the timing of this month of fast changes each year and the duration of restricted food and beverage intake can vary from between twelve to sixteen hours. Intake is restricted to the night hours within a short span of time, which thus delays sleep and reduces its duration. Environmental * Corresponding author: Tel.: [133] 1 40 77 96 63; fax: [133] 1 40 77 96 65. E-mail address: [email protected] (Y. Touitou) 0024-3205/01/$ – see front matter © 2001 Elsevier Science Inc. All rights reserved. PII: S 0 0 2 4 - 3 2 0 5 ( 0 1 )0 0 9 6 6 -3

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factors such as the timing of the rest-activity cycle [1] and meals [2–4] play a part in the synchronisation of individuals to the 24-h day (and are accordingly known as synchronisers). They modulate or modify one or several of the parameters characterising the circadian rhythm of a biologic variable [5,6]. We have previously shown that changes in the circadian rhythms of nutrition-related biological variables [7] occur during Ramadan. The purpose of the present study was to assess whether these inseparable modifications ie. long-lasting changes in food intake, sleep schedule, and psychological and social habits could modify the pattern of a set of hormonal variables including cortisol and melatonin, and therefore it was on purpose that no attempt was made to unmask the data. Methods Subjects Volunteers meeting the inclusion criteria participated in this study after giving their informed written consent. The Ethics Committee of the Faculty of Medicine of Oran approved the protocol. Ten healthy non-smoking male volunteers (medical doctors in the hospital where the study was carried on) were included in the study after routine clinical and laboratory examinations. Their ages ranged from 32 to 40 years (mean 6 SD 5 34 6 3.7 yr.). None took any medication either before or during the study; none had any chronic or acute somatic or psychiatric disorder; and none had taken a transmeridian flight within two months of the study. Protocol The volunteers were studied twice over a 24-h span: one week before Ramadan (control: end of December) and on the twenty-third day of Ramadan (Ramadan: end of January). On both test days, cortisol, melatonin, testosterone, free thyroxin (FT4), free triiodothyronine (FT3), thyroid-stimulating hormone (TSH), growth hormone (GH), prolactin (PRL), luteotropic hormone (LH), and follicle stimulating hormone (FSH) were measured from each of 6 blood samples drawn from the antecubital vein through an indwelling catheter at the following clock hours: 0815 h, 1215 h, 1615 h, 2015 h, 0015 h and 0415 h. Blood sampled during the rest time was drawn in the illumination of a dim red light (, 30 lux). Samples were allowed to clot, and the serum centrifuged, divided into aliquots, and stored at 2208C until analysed. The hormones studied were chosen because of the well-known interaction between the pineal/melatonin and the hypothalamic-pituitary / adrenal / gonadal / thyroid axes. Before Ramadan started, the subjects were synchronised to nocturnal rest from 0000 h 6 0100 h to 0700 h 6 0100 h and to diurnal activity. On test days they were awakened at 0415 h, to have their blood drawn. Physical activity did not differ qualitatively or quantitatively during Ramadan, compared with the control day (they had the same tasks and working hours before and during Ramadan). During Ramadan, except for the test day, the subjects slept uninterruptedly from 0200 h to 0800 h. Their average sleep time was thus 1 h shorter during Ramadan than it had been during the control period. Since the purpose of the study was to look for changes related to Ramadan, the lighting conditions (uncontrolled) were those habitual for the season and activity of the subjects who remained indoors during test days (same domestic intensity for all). All meals were quantitatively and qualitatively standardised by a


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nutritionist and were eaten at fixed hours that fit the subjects’ usual schedules and Ramadan customs. Meal timing and composition before Ramadan was: 0800 h: bread, butter, coffee and milk (< 400 kcal) 1200 h: meat, vegetables, bread and fruit (< 1300 kcal) 1900 h: soup, noodles, chicken (< 1000 kcal). Meal timing and composition during Ramadan was: 1900 h: milk, dates, soup, meat, vegetables, bread, fruit, coffee and pastry (< 2000 kcal) 0001 h: semolina, milk, fruit and pastry (< 600 kcal). Biochemical assays Melatonin was assayed directly by a modified version of the RIA method of Fraser et al. [8], with a [125I]-melatonin tracer, as previously described [9]. The assay sensitivity was 5–10 pg/mL, and the only significant cross-reactant was 6–hydroxymelatonin (0.1%). The intraand inter-assay coefficients of variation were respectively 9% and 8% for a concentration of 50 pg/mL, 10% and 16% for a concentration of 200 pg/mL, and 9% and 15% for a concentration of 1000 pg/mL. All other hormone variables were assayed with commercial immunofluorometry (Delphia™, Wallac, Finland). The intra- and inter-assay coefficients of variation, respectively, were as follows: for cortisol (350 nmol/L), 4.05% and 6.7%; for testosterone (20 nmol/L), 4.46% and 8.06%; for FT4 (19 pmol/L), 3.7% and 10%; for FT3 (5 pmol/L), 16% and 7.1%; for TSH (0.70 mUI/L), 2.48% and 3.5%; for LH (5 UI/L), 4.79% and 8.3%; for FSH (6 UI/L), 3% and 5.1%; for GH (0.4 mU/L), 6% and 8%; for PRL (5 ng/mL), 5.6% and 9%. Each assay was performed in one large series at the end of the protocol to minimise inter-assay variations. Statistical analysis Time series were analysed with a repeated measures analysis of variance (ANOVA; 2 within, 0 between) with SuperAnova™ software (Abacus Concepts, Inc. Berkeley, CA, USA) to test the time-related variations (effect of time in both experimental conditions), the influence of Ramadan upon the 24-h mean concentrations (Ramadan vs. control) and the possible interaction of Ramadan upon the time-related variations (experimental day and time interaction). Results ANOVA (Table 1) shows statistically significant time-related variations (Time effect) for serum melatonin, cortisol, testosterone, PRL, FSH, GH, TSH and a statistically significant decrease in the 24-h mean level of serum melatonin and FSH during Ramadan (Ramadan vs. control). Experimental day and time interaction showed that during Ramadan, compared with the control period, time-related variations of serum melatonin, cortisol, testosterone, PRL and TSH changed significantly (Table 1). Finally, no significant effect at all could be found for LH, FT3 or FT4.

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Table 1 ANOVA for repeated measures (2 within, 0 between). Biological variables documented before (Control) and on the twenty third day (Ramadan) of daytime fasting during the month of Ramadan.

Cortisol nmol/L

Melatonin pg/mL

Testosterone nmol/L

Prolactin ng/mL

FSH UI/L

LH UI/L

GH mU/L TSH mUI/L

FT3 pmol/L

FT4 pmol/L

Effect

Degree of freedom

F-Value

P-Value

Ramadan vs Control Time Experimental day and Time interaction Ramadan vs Control Time Experimental day and Time interaction Ramadan vs Control Time Experimental day and Time interaction Ramadan vs Control Time Experimental day and Time interaction Ramadan vs Control Time Experimental day and Time interaction Ramadan vs Control Time Experimental day and Time interaction Ramadan vs Control Time Experimental day and Time interaction Ramadan vs Control Time Experimental day and Time interaction Ramadan vs Control Time Experimental day and Time interaction Ramadan vs Control Time Experimental day and Time interaction

1 5 5 1 5 5 1 5 5 1 5 5 1 5 5 1 5 5 1 5 5 1 5 5 1 5 5 1 5 5

1.702 27.847 3.990 23.377 20.364 4.429 0.225 32.824 10.044 0.466 15.938 9.789 5.748 4.028 0.251 0.331 2.188 1.789 0.193 3.306 1.995 2.348 6.003 6.623 0.305 0.719 1.582 0.449 1.077 1.062

NS 0.0001 0.0044 0.0009 0.0001 0.0023 NS 0.0001 0.0001 NS 0.0001 0.0001 0.0401 0.0042 NS NS NS NS NS 0.0136 NS NS 0.0002 0.0001 NS NS NS NS NS NS

Cortisol Figure 1 shows that during Ramadan serum cortisol levels rose in the afternoon, while the morning rise was apparently delayed. This finding accords with the significant experimental day and time interaction (Table 1). Moreover, a higher morning peak and a sharper decline were observed during Ramadan. Melatonin Figure 1 shows that during Ramadan the serum levels of this hormone had a flatter slope and a smaller night peak (p , 0.008; Student’s paired t-test). This peak was also delayed, although we could not observe any change in the time melatonin secretion began with the sampling frequency used here. This agrees with the significant experimental day and time interaction (Table 1).


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Fig. 1. Patterns of serum cortisol, melatonin, testosterone, prolactin and TSH on the control day (before Ramadan) and on the twenty-third day of Ramadan. Each time point is the mean and SEM of 10 subjects.

Testosterone Figure 1 shows an obvious delay in the evening trough of serum testosterone levels (0000 h instead of 2000 h). Although the slope of the night increase in its concentration seemed unchanged, the decreased morning slope of the control day was replaced by a 0800 h–

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1600 h plateau. These changes accord with the significant experimental day and time interaction (Table 1). Prolactin The major changes in serum prolactin levels (Fig. 1) discernible during Ramadan were the increase at 2000 h and the replacement of the 0400 h–0800 h plateau by a 0800 h peak. No obvious changes were observed in either the increase or decrease slopes. TSH The decreased midnight and increased afternoon values (Fig. 1) observed on the twentythird day of Ramadan were responsible for flattening the TSH circadian rhythm which agrees with the significant experimental day and time interaction validated by the ANOVA (Table 1). Discussion Ramadan is the month during which Muslims must refrain from eating and drinking from sunrise until sunset while maintaining their usual social and occupational activities. These long-lasting modifications—daytime fasting accompanied by a delay and shortening of night-time sleep and changes in behaviour and social habits—have been shown to result in a phase delay of many biological rhythms [10–13]. Recently, we reported the alteration of the circadian patterns of plasma gastrin, insulin, glucose, calcium and gastric pH in both healthy and healed duodenal ulcer patients, and strikingly the presence of a number of these alterations one month after the end of Ramadan [7] which enforces the relevance to the debate about the strength of meal-time as a rhythm synchronizer in humans. The purpose of our study was to consider possible modifications in hormonal variables not directly linked to the timing of nutrient intake, i.e., melatonin, cortisol, testosterone, free thyroxin, free triiodothyronine, TSH, LH, FSH and GH. Because this study was carried out to examine whether these characteristics changed in humans observing the rule of Ramadan, we did not attempt to change the subjects’ environmental conditions or behavioural customs (including eating habits). Light exposure characteristics were the same during control and Ramadan periods except for the duration (one hour longer during Ramadan). Our study shows obvious modifications in the rhythmic patterns of some of the variables we studied, even though the sleep schedule of the subjects studied here was much less shortened and delayed than in another study of Ramadan-induced changes in subjects who stayed awake till dawn [11]. We must underline that: a) the subjects had the same tasks and working hours before and during Ramadan; b) they took no kind of medication either before or during Ramadan; c) none of them complained of any discomfort (including sleep disorders); d) their sleep schedule was shortened and delayed only slightly (one hour on average); e) therefore the major change in their routine was the redistribution of meal timing. The characteristics of the serum cortisol rhythm observed on the control day are concordant with those reported in the literature [6,14,15]. Nonetheless, although the mid-afternoon rise of cortisol secretion, following the mid-day meal, is a well-known and described phenomenon, it did not appear clearly among our subjects on the control day. On the Ramadan test day, the cortisol rhythm was overtly biphasic, with an evident rise in the serum concen-


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tration starting at 1200 h and a plateau between 1600 h and 2000 h, i.e., at the time of the first meal following the daytime fasting period. In addition, the morning cortisol peak was higher and steeper during Ramadan than on the control day. Such a rise, which appears to anticipate the time of feeding, has been described in food-restricted rats with access to food only during the light span [16] ie. outside of the normal activity span which is also the case for the subjects of the present study. Our data are consistent with findings in subjects on a five-day total fast (water only): they experienced delayed maximum serum concentrations and increases in the mass of their glucocorticoid secretory bursts [17]. The differences between this study and ours are most likely related to the differences between total and daytime fasting. On the other hand, probably due to the number of subjects participating in our study, we did not observe a significant increase in the 24-h mean concentration of serum cortisol. Similarly, a trend towards increased peak values of serum cortisol at 0800 h during Ramadan was suspected but was not substantiated with Student’s paired t-test. The serum melatonin rhythm observed on the control day also agreed with our previous data [15,18]. The melatonin pattern remained circadian during Ramadan even though 24-h mean concentration and amplitude decreased. The 0400 h nighttime peak concentration decreased significantly (p , 0.008; Student’s paired t-test) on the twenty-third day of Ramadan. The onset and offset times of melatonin secretion did not change from the pre-Ramadan to the Ramadan test date. The flatter slope of the melatonin increase may be due to the prolonged exposure to artificial light during Ramadan. This resulted in a peak maximum during Ramadan, rather than the plateau maximum of the control night, and it suggests that in a group of subjects who went to bed earlier during the control period, the Ramadan schedule might have caused a phase delay of the nighttime serum melatonin peak. Again, we must emphasise that since both experimental days occurred in winter, exposure to indoor lighting during Ramadan lasted only an hour longer than during the control period. To our knowledge, no other reports on melatonin circadian patterns during Ramadan fasting are available. The findings of no time-of-day variations for LH, free triiodothyronine and free thyroxin on the control day are consistent with those in the literature [6], and Ramadan did not change the pattern of these hormones. This is contrary to the report by Fedail et al. [19] who found an increase in serum thyroxin in a single sample taken before the main evening meal on the first and last days of Ramadan. This difference may well be due to the circadian basis of our study. Moreover, the duration of the daytime fasting span during Ramadan varies substantially according to the season in which it occurs. We therefore cannot rule out the possibility that this daytime fasting and accompanying changes in sleep schedule, and psychological and social habits influences the serum concentrations of LH, FT4 and FT3 when this lunar month occurs in summer rather than winter and thus substantially delays the timing of the fastbreaking meal. The well-known circadian rhythm of serum TSH was found on the control day, but its amplitude was flattened during Ramadan. The control day rhythm for serum testosterone is in agreement with previous data [19]. Ramadan did not modify the 24-h mean concentration but delayed the onset of the increase. Prolactin serum concentration was the only variable that exhibited an overt biphasic pattern on both the control and Ramadan test days, without any difference for the 24-h mean levels, but an increased evening peak. Although the profile of this hormone is known to be re-

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lated to sleep pattern, it is unlikely that the observed changes were caused by the one-hour sleep change in this study, especially since none of the subjects complained of any sleep disorder. Finally, while serum concentrations of FSH and GH underwent significant time-related variations, ANOVA failed to show any experimental day and time interaction, but did observe a statistically significant (although weak) decrease during Ramadan for the 24-h mean serum concentration of FSH. Overall, then, this study has shown different kinds of modification during Ramadan for variables considered as markers of the circadian system: melatonin maintained its circadian rhythmicity but with decreased amplitude and a trend towards a phase delay and cortisol maintained its circadian rhythmicity but with a biphasic pattern. These data indicate that these rhythms may be controlled by different oscillatory components, as other authors have suggested [21,22]. Indeed, the ten variables here studied expressed different circadian sensitivities to the altered synchronizers which would support the theory of a hierarchy of oscillators, individuality of oscillators as an alternative to a single master clock. Ramadan is in essence a seasonal external factor as it changes its annual location but besides the possible changes in the induced effects according to the duration of fasting time, one cannot rule out a superimposed seasonal variation of the sensitivity of the target rhythms (phase shifting, amplitude, mean level) to Ramadan. In conclusion, our study found that observance of Ramadan has an impact on a number of major metabolic endocrine processes. The sleep schedule of the subjects studied here was shortened and delayed only slightly (one hour on average), therefore the major change in their routine was the redistribution of meal timing. Although none of the subjects participating in this experiment complained of any discomfort, this kind of study ought to be repeated and extended to other variables and other seasons to assess the possible effects on public health of this month of daytime fasting and modifications in sleep schedule, and psychological and social habits that concerns a substantial fraction of the human population.

Acknowledgments We wish to thank Pr A. Wirz-Justice (Basel, Switzerland) and Dr A. Reinberg (Paris, France) for their useful comments, Miss Oussalah for her efficient help, and our friends and colleagues of the Hôpital Militaire Universitaire of Oran who volunteered for the study.

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