Appetite 111 (2017) 38e45

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Appetite
journal homepage: www.elsevier.com/locate/appet

Effect of Ramadan fasting on fatigue, mood, sleepiness, and health-

related quality of life of healthy young men in summer time in
Germany: A prospective controlled study
Boya Nugraha a, b, *, Samaneh Khoshandam Ghashang a, Imad Hamdan a,
Christoph Gutenbrunner a
a
Department of Rehabilitation Medicine, Hannover Medical School, Germany
b
Graduate Program Faculty of Medicine, Universitas Gadjah Mada, Yogyakarta 55281, Indonesia

a r t i c l e i n f o a b s t r a c t

Article history: Muslims around the world fast during the lunar month of Ramadan. The month consists of 29 or 30 days,
Received 20 July 2016 which vary in length depending on geographic location and the time of year. During this month, Muslims
Received in revised form abstain from food, drink, smoking, and sex from dawn until sunset. In 2015, Ramadan fell during the
14 December 2016
summer. As a result, Muslims in Germany fasted 19 h a day.
Accepted 21 December 2016
Available online 24 December 2016
Previous research has shown associations between fasting and mood enhancement. This study aimed
to determine the effect of fasting on young, healthy males who fasted in Germany during Ramadan 2015.
In particular, this study examined the impact of fasting on mood, fatigue, and health-related Quality of
Keywords:
Ramadan
Life (QoL).
Fasting This study had 2 groups: fasting group (FG; n ¼ 25), and non-fasting group (NFG; n ¼ 25). In FG,
Fatigue participants were assessed at four different points: one week before Ramadan (T1), mid Ramadan (T2),
Mood the last days of Ramadan (T3), and one week after Ramadan (T4). In NFG, participants were assessed only
Quality of life at T1 and T3.
The results revealed that there were no significant differences between the participants in the FG and
the NFG at T1 or T3 for any of the outcomes. However, participants in the FG demonstrated significant
improvement from T2 to T4 in fatigue (visual analogue scale p < 0.01; fatigue severity scale:p < 0.01),
mood (Beck's Depression Index-II; ANOVA; p < 0.05), and sleepiness during day time (Epworth Sleepi-
ness Scale: ANOVA; p < 0.01). Participants in the FG also experienced significant loss of body weight
(ANOVA; p < 0.001), body mass index (ANOVA; p < 0.001), skeletal muscle mass (ANOVA; p < 0.01) and
fat free mass (ANOVA; p < 0.01).
Findings demonstrate that Ramadan fasting did not significantly influence mood, fatigue and QoL,
when compared to NFG. Even, it gives benefit to fasting group with regard to these parameters.
© 2016 Elsevier Ltd. All rights reserved.

1. Introduction
Fasting has been practiced by many religions and cultures
around the world for many centuries. In Islam, fasting during
Ramadan is an obligatory duty for Muslims (Quran, 2:183).
Ramadan lasts for 29 or 30 days. During this month, Muslims
abstain from food, drink, smoking, and sex from dawn until sunset
* Corresponding author. Department of Rehabilitation Medicine, Hannover
Medical School, Carl-Neuberg-Str.1, 30625, Hannover, Germany.
E-mail addresses: Nugraha.boya@mh-hannover.de, boya.nugraha@gmail.com
(B. Nugraha).
(Quran, 2:187). The length of the fast depends on the time of year
and the location of the person fasting. In Hannover, Germany,
people began their fast on the first day of Ramadan 2015 at about
2:45 and ended their fast at about 21:45 local time. Every day, the
length of the fast changed as the time for dawn and sunset changed.
Many different studies in different type of fasting demonstrated
its benefit for both healthy subjects and patients with particular
conditions, like multiple sclerosis (Choi et al., 2016; Etemadifar
et al., 2016; Fahrial Syam, Suryani Sobur, Abdullah, & Makmun,
2016; Michalsen, 2010). Fasting has also been recommended as
therapy (Michalsen & Li, 2013; Wilhelmi de Toledo et al., 2013).
For Muslims, fasting is not perceived as a physical punishment,

http://dx.doi.org/10.1016/j.appet.2016.12.030
0195-6663/© 2016 Elsevier Ltd. All rights reserved.
 B. Nugraha et al. / Appetite 111 (2017) 38e45
but a blessing with many rewards, particularly spiritual. Studies on
the effect of Ramadan on body composition, hormones, and glucose
level have been reported both in healthy and different types of
patients (Askari, Alavinezhad, & Boskabady, 2016; Fahrial Syam
et al., 2016; Fawzi et al., 2015; Lessan, Hannoun, Hasan, &
Barakat, 2015; Yeoh et al., 2015). Although in some other health
condition groups (e.g. diabetes), health professionals should
monitor the patients’ during Ramadan fasting (Yeoh et al., 2015).
Fasting has also possible benefits with regard to mood
enhancement and increased vigilance. The neurobiological mech-
anism of fasting with particular topic on mood has been reported in
a comprehensive review (Fond, Macgregor, Leboyer, & Michalsen,
2013). Referring to the results of this review, it is necessary to
evaluate its effect in other type of fasting, including Ramadan.
Moreover, to the best of our knowledge, there is still a lack of in-
formation and evidence regarding the effect of Ramadan fasting on
mood, fatigue and health-related quality of life, particularly in
summer time in Europe, which has longer day time and thus longer
fasting time as compared to other southern European countries.
Additionally, there is a need to have a controlled study in Ramadan-
related research, as most of the other available studies had pre-post
study design. Therefore, this study aimed to determine the effect of
Ramadan fasting on fatigue, mood, and other health-related QoL in
a prospective controlled trial. The body composition parameters,
including body weight (BW), skeletal muscle mass (SMM), body fat
mass (BFM), fat free mass (FFM), body fat percentage (BFP), body
water (BW) and wait and hip ratio (WHR) were also measured.
2. Material and methods
This study was approved by the local ethics committee, Hann-
over Medical School (Ethics No. 6899) and was performed in
accordance with the ethical standards laid down in the 1964
Declaration of Helsinki. All patients agreed to participate on the
basis of informed consent. This study had been conducted in
Ramadan 2015: JuneeJuly 2015.
2.1. Participants
Healthy male volunteers were recruited (mostly students from
Hannover Medical School) and divided into two groups. The first
group planned to fast during Ramadan (fasting group; FG), the
other group (non-fasting group; NFG) did not fast. To be eligible
into the FG, participants had to: (1) be healthy, (2) be older than 18
years of age, (3) intend to fast the whole month of Ramadan, (4)
have fasted during Ramadan at least once before, (5) understand
the German or English language. For the NFG, all subjects had to
meet the criteria of the FG, except that they would not be fasting.
In the fasting group, all study end points were measured at four
time points (Table 1). The first end point of the study/baseline (T1)
was one week before the beginning of Ramadan (June 2015). The
second end point was in the middle of Ramadan (T2: day 14th or
15th or 16th). The third end point was during the last days of
Ramadan (T3: day 28th or 29th or 30th). The last end point was
assessed at one week after the Ramadan fasting finished (T4:
Table 1
Time point of assessment.
Group Time point of assessment
T1 T2
(baseline: 1 week before Ramadan) (mid of Ramadan)
Fasting Group (FG) (n ¼ 25) √ √
Non-Fasting-Group (NFG) (n ¼ 25) √ e
39
day þ6th, þ7th, þ8th from the end of Ramadan).
In the NFG, there were only 2 time points for measuring end-
points, which were before Ramadan (T1) and during the last days of
Ramadan (T3).
2.2. End points
Primary endpoints were mood, fatigue and health related QoL.
These were assessed by using self-administered questionnaires.
The Hospital Depression and Anxiety Score (HADS) and Beck's
Depression Inventory (BDI)eII were used to assess the intensity of
mood (anxiety and depression or only depression, respectively).
HADS is a fourteen-item scale, which consists of seven items
relating to anxiety and seven relating to depression (Zigmond &
Snaith, 1983). The score of each parameter is from 0 to 21. A score
of 8 or more indicates symptoms of anxiety/depression. BDI-II is a
self-reporting questionnaire to measure the severity of depression.
It consists of 21 questions. The lowest score is zero and the highest
score is sixty-three. The higher the score is the more severe the
depression (Wang & Gorenstein, 2013).
Fatigue was measured by the visual analogue scale (VAS) and
fatigue severity scale (FSS). VAS is a unidimensional assessment
tool from 0 (no fatigue) to 10 (the worst imaginable fatigue), and
FSS is a nine-item questionnaire to evaluate the impact of fatigue.
Each question consists of statements that are scored from 1
(strongly disagree) to 7 (strongly agree). The cut-off are different
across health conditions (Valet, Stoquart, Glibert, Hakizimana, &
Lejeune, 2016).
Day sleepiness was measured by using the Epworth Sleepiness
Scale (ESS), ESS is a self-administered questionnaire with 8 ques-
tions. Each question can be rated on a 4-point scale (0e3). ESS score
is the sum of 8 questionnaires that can range from 0 to 24. The
higher the ESS score, the higher that person's average propensity in
daily life of daytime sleepiness (Xiong et al., 2016).
The 12-short form questionnaire (SF-12) is a multipurpose
questionnaire with 12 questions. This questionnaire consists of
mental and physical functioning (Ware, Kosinski, & Keller, 1996).
Parameters related to body composition, including body weight
(BW), skeletal muscle mass (SMM), body fat mass (BFM), body mass
index (BMI), fat free mass (FFM), and percentage of body fat (PBF)
were also measured by using InBody machine (InBody 230; Model
MW160, Korea).
2.3. Statistics evaluation
The Saphiro-Wilk test was used to check the normality of the
data. ANOVA repeated measure was used to compare significant
differences in different time points (followed by post hoc test with
Bonferroni correction). Student's t-test or Mann-Withney U test
(depend on data distribution) was used to compare baseline T1 and
T3 of FG and NFG for each parameter. The mean imputation method
was used for handling missing value. Statistical analysis was per-
formed by using SPSS version 22 (IBM, New York, USA). Significant
was set at p < 0.05. Explorative statistics analysis such as correla-
tion of body composition parameters with mood, fatigue,
T3 T4
(on the last days of Ramadan) (one week after the Ramadan)
√ √
√ e
40 B. Nugraha et al. / Appetite 111 (2017) 38e45

sleepiness and health related QoL of the subjects were performed.
Considering this was a pilot study, 25 samples were decided for this
study (Hertzog, 2008).
3. Results
3.1. Subject recruitment and screening
Fig. 1 shows the flow of the participant throughout the study.
Ninety-three males (mostly students at Hannover Medical School)
were asked to participate in this study. Forty and fifty-three males
volunteered to participate in FG and NFG, respectively. However,
due to various reasons – such as conflicting schedules, anxiety of
giving blood, distance from the study centre, and other reasons – 28
males (FG) and 26 males (NFG) were able to participate at T1.
Finally, we included 25 males for data analysis both in FG and NFG.
3.2. Baseline data
The results of baseline data of FG and NFG are demonstrated in
Table 2. There were no differences at baseline between the FG and
NFG groups for any of the outcomes.
3.3. Effect of Ramadan fasting
3.3.1. Fatigue, mood, and health-related QoL
Table 3 shows the results of mood, fatigue and QoL at before,
during and after Ramadan in both FG and NFG. Comparing any of
the outcome parameters of FG and NFG, no significant differences
were seen at T1 or T3. The effect of summer time fasting during
Ramadan in Germany on fatigue, mood, and health-related QoL is
demonstrated in Table 3. Additionally, the effects on fatigue (VAS),
fatigue severity scale (FSS), mood (BDI-II), and sleepiness (ESS) are
demonstrated in Fig. 2. In FG, fatigue score, which was measured by
VAS, showed significant differences across the time points. During
the first week of Ramadan (T1), the fatigue score of the FG increased
to a moderate level and then gradually decreased until T4 (ANOVA;
p < 0.005). Even significant reduction of fatigue score (VAS) was
demonstrated when comparing T1 with T2 (p < 0.05), T2 with T4
(p < 0.005) and comparing T3 and T4 (p < 0.01). Meanwhile, when
FSS was used to measured fatigue, the trend of reduction was
gradually observed from T1 to T4 (ANOVA; p < 0.01). The significant
difference was seen when comparing T1 with T4 (p < 0.05).
Sleepiness during day time was assessed by using ESS. Significant
reduction of the ESS score was demonstrated (ANOVA; p < 0.005).

93 males were asked and screened

40 interested in parƟcipating in 53 interested in parƟcipating in

fasƟng group non-fasƟng group

10 refused: 15 refused:
- Ɵme schedule (n=2); - Time schedule (n=1);
- Did not want blood drawn (n=1); - Did not want blood drawn (n=2)
- Distance (n=1); - Distance (n=1);
- Other reasons (n=6) - Sick (n=1);
2 were not eligible - Other reasons (n=10)
12 were not eligible

28 visited T1 fasƟng group 26 visited T1 in non-fasƟng group

1 refused (other reason)

27 visited T2 fasƟng group 1 refused (other reason)

1 refused (Ɵme schedule)

26 visited T3 fasƟng group 25 completed Ɵll the end of study (T3)

1 refused (Ɵme schedule)

25 visited T4

25 included in the data analysis 25 included in the data analysis

Fig. 1. Flow chart of recruitment.

 B. Nugraha et al. / Appetite 111 (2017) 38e45 41

Table 2 observed. Significant changes occurred in BW and BMI when

Baseline data of fasting and non-fasting group. comparing T1 with T2 (BW:p < 0.005; BMI p < 0.005), T3
FG (N ¼ 25) NFG (N ¼ 25) p (BW:p < 0.001; BMI:p < 0.001) and T4 (BW:p < 0.001;
Mean ± SEM Mean ± SEM
BMI:p < 0.001). In addition, the significant changes of these pa-
rameters can also be seen during T2 and T3 (BW:p < 0.005;
Age 26.12 ± 0.98 26.20 ± 0.98 0.977
BMI:p < 0.05). The impact on BW and BMI are large as can be seen
White/Asian 21/4 16/9 0.196a
Body Composition from partial eta squared. SMM was significantly reduced, with
BW (kg) 77.82 ± 2.46 76.16 ± 4.29 0,739 medium effect size (partial eta squared). Pairwise comparison
BMI (kg/m2) 24.78 ± 0.73 24.56 ± 0.78 0.840 showed the significant difference of SMM T1 with T3 (p < 0.05); T2
SMM (kg) 34.66 ± 1.02 34.60 ± 1.05 0.972
and T3 (p < 0.005); as well as T3 compared to T4 (p < 0.005). FFM
BFM (kg) 16.65 ± 1.48 17.44 ± 1.68 0.726
FFM (kg) 61.18 ± 1.72 61.10 ± 0.176 0.980 was also reduced significantly at T2 compared with T3 (p < 0.005);
BFP (%) 20.92 ± 1.41 21.54 ± 1.41 0.797 and at T3 compared with T4 (p < 0.005). BFP was significantly
BWM (kg) 44.88 ± 1.25 44.77 ± 1.80 0.960 increased at T3 compared with T4 (p < 0.05). Meanwhile, there
WHR 0.88 ± 0.04 0.92 ± 0.02 0.293 were no significant differences of T1 and T3 in NFG in all
HADS
parameters.
Anxiety (HADSA) 4.92 ± 3.82 4.26 ± 3.38 0.521
Depression (HADS D) 4.36 ± 3.88 3.06 ± 3.47 0.218
Depression (BDI-II) 8.36 ± 8.21 6.48 ± 5.97 0.359 4. Discussion
SF-12
Physical Health 52.60 ± 5.35 53.67 ± 3.64 0.414
The purpose of the study was to determine the effect of
Mental Health 49.48 ± 10.83 49.23 ± 11.12 0.936
Fatigue Ramadan fasting on fatigue, mood and health-related QoL in
Fatigue (VAS) 3.01 ± 1.83 3.08 ± 1.96 0.893 healthy males during summer time in Germany. Additionally, body
Fatigue Severity Scale (FSS) 26.92 ± 8.65 26.44 ± 10.38 0.860 composition-related parameters were also determined. Ramadan
Epworth Sleepiness Scale (ESS) 7.96 ± 3.81 7.16 ± 3.73 0.457 time in 2015 in Germany had long day, because it was in summer
All data are presented in Mean ± SEM; Student's T-test. season. Due to this issue, many people were concerned about the
a
Fischer's Exact test. impact of fasting so long on the human body. Therefore we studied
its effect on healthy people, particularly in young male subjects.
Moreover, to the best of our knowledge, there is a lack of pro-
The significant difference could be seen when comparing T1 with
spective control studies with regard to Ramadan fasting.
T4 (p < 0.005) and T2 with T4 (p < 0.05). Mood related symptoms
Our findings could not demonstrate significant differences be-
were measured by using BDI-II and HADS. In BDI-II, there was
tween the FG and the NFG in all parameters, particularly during the
significant difference along the study period (ANOVA; p < 0.05),
last days of Ramadan (T3). Interestingly, within-group difference
pairwise comparison showed significant reduction of the BDI-II
showed that the FG has positive effects on mood, fatigue, and QoL
score when comparing T2 with T4 (p < 0.05). There was no sig-
during Ramadan period until T4.
nificant differences in anxiety (HADS-A), depression (HADS-D) or
mental and physical health.
4.1. Comparison of FG and NFG

3.3.2. Body composition
Table 4 demonstrates results of body composition related pa-
rameters at before, during and after Ramadan in both FG and NFG.
There were no significant differences could show in all parameters
at both T1 and T3 when comparing FG and NFG. However, the
significant reduction in BW, BMI, SMM, and FFM in the FG were
With regard to no significant differences between groups, these
results were not expected since those fasting change their eating
and sleeping patterns during Ramadan. Most people usually have
three meals per day outside of Ramadan. However, during
Ramadan, people eat just twice per day (before dawn and after
sunset). Though they eat less often, many people eat foods richer in

Table 3
Fatigue, Mood and health-related QoL before, during, and after Ramadan.

Time Points p p& Partial

(FG: ANOVA; NFG:paired t-test) h2
T1 T2 T3 T4

Group Mean ± SEM Mean ± SEM Mean ± SEM Mean ± SEM

Fatigue (VAS) FG (N ¼ 25) 3.01 ± 0.35a, 4.93 ± 0.59e 2.94 ± 0.35f 1.81 ± 0.26 0.001 0.372 0.200
NFG (N ¼ 25) 3.08 ± 0.39 3.43 ± 0.41 0.516
Fatigue Severity Scale FG (N ¼ 25) 2.99 ± 0.19c 2.72 ± 0.20 2.64 ± 0.24 2.28 ± 0.22 0.008 0.860 0.151
NFG (N ¼ 25) 2.93 ± 0.23 3.09 ± 0.24 0.445
Epworth Sleepiness Scale FG (N ¼ 25) 7.96 ± 0.76c 7.33 ± 0.74 e
6.68 ± 0.88 5.16 ± 0.87 0.001 0.642 0.200
NFG (N ¼ 25) 7.16 ± 0.75 6.12 ± 0.81 0.147
Depression (BDI-II) FG (N ¼ 25) 8.36 ± 1.64 8.50 ± 1.14e 6.63 ± 1.08 4.92 ± 1.03 0.046 0.671 0.140
NFG (N ¼ 25) 6.48 ± 1.19 5.96 ± 1.13 0.507
Anxiety FG (N ¼ 25) 4.92 ± 0.76 4.71 ± 0.74 4.16 ± 0.73 4.02 ± 0.67 0.398 0.774 0.037
(HADS-A) NFG (N ¼ 25) 4.26 ± 0.68 4.46 ± 0.74 0.785
Depression (HADSD) FG (N ¼ 25) 4.36 ± 0.78 4.25 ± 0.71 4.16 ± 0.59 2.96 ± 0.60 0.109 0.218 0.093
NFG (N ¼ 25) 3.06 ± 0.69 2.84 ± 0.65 0.600
Physical Health FG (N ¼ 25) 52.60 ± 1.07 51.13 ± 1.22 50.29 ± 1.49 51.74 ± 1.10 0.406 0.303 0.041
NFG (N ¼ 25) 53.67 ± 0.73 52.21 ± 1.09 0.139
Mental Health FG (N ¼ 25) 49.48 ± 2.17 52.42 ± 1.88 52.09 ± 1.62 52.42 ± 1.65 0.231 0.394 0.062
NFG (N ¼ 25) 49.23 ± 2.22 49.90 ± 1.96 0.630

p: ANOVA test; followed by pairwise comparison with Bonferroni correction for multiple test. Significant difference a: T1vsT2; b: T1vsT3; c:T1vsT4; d:T2vsT3; e: T2vsT4;
f:T3vsT4; p& value between group at T3.
42 B. Nugraha et al. / Appetite 111 (2017) 38e45

FaƟgue (VAS) FaƟgue (FSS)

7.00 ** 3.50 **
*
6.00 3.30
**
3.10
Visual Analogue Scale
5.00 2.90
4.00 2.70

FSS Score
2.50
3.00 2.30
2.00 2.10
1.90
1.00
1.70
- 1.50
1 2 3 4 1 2 3 4
Time point Time point

Mood (BDI-II) Sleepiness (ESS)

*
**
10.50 10.50
9.50 9.50 *

8.50 8.50
BDI-II Score

ESS Score

7.50 7.50
6.50 6.50
5.50 5.50
4.50 4.50
3.50 3.50
1 2 3 4 1 2 3 4
Time point Time point

Fig. 2. Effect of Ramadan fasting on fatigue severity scale, fatigue (VAS), mood (BDI-II), and sleepiness during day time (ESS). *p < 0.05; **p < 0.01; ***p < 0.001. Non-Fasting Group
(n ¼ 25); Fasting group (n ¼ 25).

Table 4
Body composition before, during, and after Ramadan.

Time Points p (FG: ANOVA; NFG:paired t-test) p& Partial

h2
T1 T2 T3 T4

Group Mean ± SEM Mean ± SEM Mean ± SEM Mean ± SEM

BW (kg) FG (N ¼ 25) 77.82 ± 2.46a,b,c 76.73 ± 2.52d 76.04 ± 2.54 76.54 ± 2.51 0.000 0.684 0.547
NFG (N ¼ 25) 76.16 ± 4.29 77.81 ± 3.50 0.000
2
BMI (kg/m ) FG (N ¼ 25) 24.78 ± 0.73a,b,c 24.44 ± 0.73 d
24.22 ± 0.73 24.35 ± 0.72 0.000 0.927 0.509
NFG (N ¼ 25) 24.56 ± 0.78 24.32 ± 0.75 0.075
SMM (kg) FG (N ¼ 25) 34.6 ± 1.02b 34.48 ± 1.01d 33.94 ± 1.05f 34.52 ± 1.03 0.005 0.730 0.206
NFG (N ¼ 25) 34.6 ± 1.48 34.58 ± 1.52 0.945
BFM (kg) FG 16.65 ± 1.48 15.76 ± 1.42 17.29 ± 1.94 15.59 ± 1.38 0.257 0.726 0.056
(N ¼ 25)
NFG (N ¼ 25) 17.44 ± 1.68 16.74 ± 1.64 0.183
FFM (kg) FG (N ¼ 25) 61.18 ± 1.72 60.93 ± 1.70d 60.12 ± 1.76f 60.95 ± 1.72 0.009 0.980 0.118
NFG (N ¼ 25) 61.11 ± 2.49 61.07 ± 2.56 0.914
BFP (%) FG (N ¼ 25) 20.92 ± 1.41 20.06 ± 1.31 20.46 ± 1.26f 19.68 ± 1.34 0.029 0.797 0.142
NFG (N ¼ 25) 21.54 ± 1.41 20.96 ± 1.47 0.290
BWM (kg) FG (N ¼ 25) 44.88 ± 1.25 44.72 ± 1.25 42.02 ± 2.02 44.71 ± 1.26 0.078 0.960 0.122
NFG (N ¼ 25) 44.77 ± 1.80 44.73 ± 1.86 0.329
WHR FG (N ¼ 25) 0.88 ± 0.0.04 1.26 ± 1.81 0.90 ± 0.06 0.89 ± 0.07 0.323 0.635 0.041
NFG (N ¼ 25) 0.92 ± 0.02 0.91 ± 0.06

p: ANOVA repeated measures test; followed by pairwise comparison with Bonferroni correction for multiple test. Significant difference: a: T1vsT2; b: T1vsT3; c:T1vsT4;
d:T2vsT3; e: T2vsT4; f:T3vsT4; or p value for paired T p& value between group at T3.
 B. Nugraha et al. / Appetite 111 (2017) 38e45
fat and protein during Ramadan than in other months (Leiper,
Molla, & Molla, 2003). This might also be a reason for not having
significant differences between groups in this study with regards to
body composition related parameters. No food and fluid for a long
time could increase the chances of hypoglycaemia, a condition
which would cause fatigue, headache, mental idleness and confu-
sion (Hamilton, Whitney, & Sizer, 1991). However, in this study,
these effects were not significantly different when comparing the
FG and the NFG with regard to fatigue, sleepiness, mood and
health-related QoL. As fatigue and sleepiness are part of physical
performance factors, the results of this study were in agreement
with other studies that showed no effect on physical performance
during Ramadan (Yasin, Khattak, Mamat, & Abu Bakar, 2013).
Unfortunately, in this study we did not measure parameters of
NFG at two other time points, particularly at one week after
Ramadan (T4). The first main end point was to observe and
compare the effects of fasting during Ramadan, which required a
comparison of individuals on the first and last days of Ramadan.
Therefore, we only measured two time points in the NFG (T1 and
T3). Other reason was related to organizational issue within our
department. However, it would also be of interest to measure all
parameters at T4 in both groups as some parameters tended to
change (either gradually increased or decreased) until T4 in the FG.
Interestingly, by having the NFG as a control group and comparing
all parameters with the FG at the last days of Ramadan (T3), there
was no significant negative effect shown of fasting through the long
German summer days. Fasting during Ramadan thus does not have
negative effects with regard to fatigue, sleepiness, mood, health
related-QoL, and body composition-related parameters.
4.2. Fasting and fatigue, mood, and QoL in FG
Fatigue can be defined as a subjective experience, and includes
such symptoms as rapid inanition, persisting lack of energy,
exhaustion, physical and mental tiredness and apathy (Valko,
Bassetti, Bloch, Held, & Baumann, 2008). Therefore, fatigue could
be one of the important factors to be determined during Ramadan
fasting. It is related to the performance of all people, including
students and workers. In this study, fatigue was measured with
both VAS and FSS. The higher the score, the worse the fatigue. In the
FG, the fatigue scores, which were measured both with VAS and
FSS, improved until the last time point (T4; one week after
Ramadan). In FSS the score gradually decreased from T1 to T4.
Interestingly, the fatigue score with VAS increased at T2 and then
decreased until T4. The increase at T2 could be due to adaptation
during Ramadan. The results of these fatigue scores during the
study period showed a discrepancy as compared to other studies
that showed an increased level of fatigue in nurses fasting during
Ramadan fasting (Ovayolu, Ovayolu, & Tasan, 2016), and slight in-
crease in male elite judo athletes (Chaouachi et al., 2009). Some
reasons could be including characteristics of participants, activities,
and assessment tools for fatigues.
In this study the effect of sleepiness during day time was
measured with ESS. The ESS is a validated questionnaire that as-
sesses the likelihood that the subject will fall asleep during certain
activities (Xiong et al., 2016). Our result in FG showed the score of
ESS was in the normal range. Interestingly, ESS score improved
gradually until T4. Even the score decreased significantly
comparing T1 with T4 and T2 with T4. This result has discrepancy
as compared to the other study (Bahammam, Almushailhi, Pandi-
Perumal, & Sharif, 2014) which showed no differences. This dif-
ference could be because of several reasons, particularly study
design. Interestingly, Bahammam et al. designed the fixed-sleep-
wake schedule and fixed caloric intake in their study which
resulted in no impact on daytime sleepiness. This is quite
43
interesting, as in our study designed, it reflected the real life situ-
ation of participants. Another explanation for any discrepancy
could be different assessment time points (Roky et al., 2003).
There is a lack of information of fasting's impact on mood during
Ramadan. In the FG, an improvement of BDI-II score was observed.
This result was consistent with other studies that showed people
fasting to experience a decrease in depression during and after
Ramadan (Koushali, Hajiamini, Ebadi, Bayat, & Khamseh, 2013).
Another consistency could be seen in a 2-year study of calorie re-
striction, as it showed improvement of mood which was measured
with BDI-II (Martin et al., 2016). However, we could not see sig-
nificant differences in anxiety and depression that were measured
with HADS-A and HADS-D, respectively. That we did not observe
any significant difference in anxiety is consistent with another
study that could not show differences when comparing fasting
nurses before and after Ramadan (Koushali et al., 2013). However in
that study, it had a pre-post study design with 2-time point
assessment, which was before and after Ramadan. In our study, we
had a control prospective study determining the effect of Ramadan
fasting on mood, fatigue and health related QoL at before, during
and after Ramadan fasting. Therefore this study is more compre-
hensive as it also monitored its effect during Ramadan period.
HADS and BDI-II showed different results in the alteration of mood
before, during and after Ramadan. This difference could be that
BDI-II is sensitive to change in depression cross cultural studies
(Smarr & Keefer, 2011). With regard to mental and physical health,
no significant differences occurred, although the trend of the
mental health was increased.
4.3. Fasting and body composition in FG
Our results showed the alteration of BW and BMI in the FG
comparing baseline to the other time point of assessments. The
reduction of BW and BMI could be the result of reduction of SMM
and BFM as we could also observe in this study. These results are in
line with other previous studies (Norouzy et al., 2013; Rahman,
Rashid, Basher, Sultana, & Nomani, 2004; Ziaee et al., 2006).
Interestingly, some other studies could not show the effect of
Ramadan on body composition (Ramadan, 2002; Yucel,
Degirmenci, Acar, Albayrak, & Haktanir, 2004).
The SMM was reduced significantly from baseline until the last
days of Ramadan, although it returned to the baseline level after
one week of Ramadan. But it was only slightly reduced (1.91%) as
compared to the baseline. This reduction could be the result of
protein breakdown during fasting (Bak et al., 2016). Another
Ramadan fasting study showed no reduction in protein mass
because of Ramadan fasting. Some factors could be responsible for
this discrepancy, particularly the duration of the fasting. Our fasting
duration was about 19 h per day, meanwhile in the other study, the
fasting duration was about 13e14 h per day. Prolonged fasting can
lead to the catabolic state that increases gluconeogenesis with
proteolysis, thus decreasing protein mass (Fahrial Syam et al.,
2016). In the fasting period, the availability of carbohydrates is
limited and lipids become the major source of energy for substrate
metabolism. Other sources of energy include the utilization of
amino acids from muscle protein which is markedly by the increase
of net phenylalanine release from skeletal muscle (Vendelbo et al.,
2014). However the latter study was reported from the 72 h fasting
period. Thus it cannot be directly compared to the Ramadan fasting
study. Additionally, our study had different fasting methodology
and interestingly, the level of skeletal muscle returned to the
baseline only within one week after one month fasting. However,
we did not measure the muscle metabolism.
Our results suggest that Ramadan fasting can be done in healthy
young males without concerning negative effect on their mood,
44 B. Nugraha et al. / Appetite 111 (2017) 38e45
fatigue and QoL. Even, in Ramadan fasting, it can give benefits with
regard to mood, fatigue and health-related QoL for fasting partici-
pants. As this study was assessed only in healthy male subjects,
these benefits should be studied further in different health condi-
tions, among females, and different range of ages.
This study had some limitations. The participants could not be
randomised due to ethical/religious reasons. Additionally, we did
not control and record the calorie intake of all participants along
the study period. This is because we wanted to determine the
natural effect of fasting during Ramadan based on the actual diet of
the participants. All of the questionnaires are self-report and
measurements were filled in the morning time. Most of the par-
ticipants in the FG were students, but this was compensated as the
NFG had similar participants. The measurement time points in NFG
were only at T1 and T3. Measurement of metabolite markers for fat,
protein, and mood related-markers would be interesting to deter-
mine the alteration these parameters.
5. Conclusion
Findings demonstrate that Ramadan fasting did not significantly
influence mood, fatigue and QoL, when compared to non-fasting
control. Even, it gives benefit to fasting group with regard to
these parameters. Further studies are needed to evaluate the
pathomechanism or metabolism of this effect.
Funding
This was supported by Department of Rehabilitation Medicine,
Hannover Medical School, Germany.
Declaration of interest
Nothing to be declared.
Acknowledgements
We would like to thank Amin Riath, Muatasem Abu Kaf, and
Dominique Dimmek for their technical assistance during recruit-
ment process of the study. We would also like to thank Mr. Ali
Tehrani, JD (Juris Doctor) as a native English speaker who checked
this manuscript.
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