Wednesday, June 5, 2013

Ramadan Improves Body Composition of Young & Older Men, Young Women Don't Benefit and Women >37y Become Fat During the Fast - Implications for Intermittent Fasting?

It may not be "paleo conform", there but the traditional Ramadan menu is 100% home-made from fresh foods - that alone will make a huge difference.
"I hear you..." What's that supposed to mean? Well, in a way I am running the SuppVersity for me, because I like the idea that people like you come here and think "Hey, today I've learned something new", "... read something interesting" or at even"... have been enlightened". On the other hand, this entails that I got to tailor the topics to your interests as well and since the short Facebook item on the effects of Ramadan fasting on body composition I posted on Facebook, a couple of days ago, which spiked so much interest, I will take it up and write a whole article about this soon-to-be-published study from the Mashhad University of Medical Science and the University of Nicosia (Norouzy. 2013).

Ramadan is not "intermittent fasting"...

... at least not in the sense it's interpreted by most people.In fact, there are a whole host of differences one could think about, but for our purpose which is the use of intermittent fasting as a way to live healthier and/or improve our physique these are just a couple of examples that come to mind:
  • Effect of Ramadan fasting on perceived snack, fluid and food intake in 411 male and 323 female Malaysian Junior Level Muslim athletes (data calculated based on Singh. 2011; originally posted as part of the Intermittent Thoughts on Intermittent Fasting on Sept. 06, 2011)
    The fasting window can actually be pretty small - While all Muslims will eat the lions-share of their energy intake in the evening many rise early (esp. when Ramadan falls into the winter months) and ingest a medium sized breakfast to "make it through the day".
  • Food quality (from a health perspective) is not always ideal - While researchers have observed that there seems to be an unconcious increase in protein intake (+6.6% protein; less carbs and fats; Trabelsi. 2011), this is yet not a characteristic feature of the protocol, but rather a result of dining with the family, not snacking and putting an emphasis on whole self-prepared (and more expensive) food.
  • During the fast Muslims don't drink - This is obviously something anybody following a "lean gains" like intermittent fast or an "alternative day fasting" protocol, where people eat only 500kcal or so two or three times a week and just follow their habitual diet on the other days would not remotely consider. However, in a paper published in the European Journal of Clinical Nutrition in 2003, Leiper, Molla and Molla report that despite the fact that "[d]uring the daylight hours of Ramadan fasting, practising Muslims are undoubtedly dehydrating", it is neither "clear whether they are chronically hypohydrated" nor have there been any "detrimental effects on health [...] directly attribut[able] to negative water balance at the levels that may be produced during Ramadan" observed in any scientifically relevant studies (Leiper. 2003). It is thus relatively safe for us to assume that we can neglect he influence of potential dehydration in our initial analysis of respective studies.
  • Other differences  - I guess, I better spend time discussing the latest study and refer you to the Intermittent Thoughts Series, where I discussed the existing differences and implication at length. You can browse the articles here. Start with the first post "Myth #1: A Higher Meal Frequency Equals a Higher Metabolic Rate" from September 4th, 2011 and click yourself through the  rest of the series. You won't regret reading it, I promise ;-)
A one-to-one translation of the results from the study at hand to your efforts of a practical and effective way to lose body fat (this is where it excels - and not in "lean gaining") is thus unwarranted. There may yet still be a couple of things, we can learn from what the observations the Iranian and Greek researchers made in their 240 adult subjects (male: 158) who fasted between sunrise and sunset for at least 20 days.
Figure 1: Body weight and composition before and after Ramadan and percentage changes from baseline according to gender and age; data expressed relative to baseline (Norouzy. 2013)
As the data in figure 1 goes to show you the overall pattern that emerges is positive one. However, the weight the subjects, who were grouped according to age and sex, lost was (as it was to be expected, by the way) not pure fat mass. Still, with the exception of older women all subjects improved their body fat levels.

Is intermittent fasting not for women?

Apropos women, it's not just that the older women (>37y) did actually gain body fat, the already minimal reduction in body fat (%) in the younger women was also non-significant (p = 0.079 vs. p=0.029 in men). Taken together these results appear to suggest that a non-controlled, intermittent fasting regimen that's based solely on the absence of food intake in the course of the day would be beneficial for men only.

Looks good, tastes good, is good - high protein foods! Unfortunately many  women (obyiously not you, right) have still not gotten the message that by simply making sure you have 30g+ of protein in your three-square meals is probably the easiest way to improve both your physique and health. Still, the study at hand provides further evidence that a low protein intake is not all that makes it more difficult for women to lose fat (learn more)
It should be said, though, that these results stand in conflict with previous studies by Husain et al. who report more, not less weight and body fat loss in the 20-45 year-old female subjects of their Ramadan fasting study (Husain. 1987). An observation they pin on the "increase in energy expenditure" that comes with preparing the meal for the whole family... well, you know that I am not afraid of calling *bs* by its name and this explanation certainly is*bs*. It is in fact much more likely that the differences could be explained by a lower overall energy intake just as the increase in body weight Frost & Pirani observed in the young men in another cohort was solely a result of the nightly binges (Frost. 1987). I mean, we all know that women are more likely to be concerned about the detrimental effects of a high food intake in the evening on their body composition, so that it is not unlikely that the 20-45 year old women in the Husain study were deliberately limiting their energy intake, while the men in the study by Frost & Pirani gave in to their ravenous appetite and the delicious meals their wifes, sisters and aunts had prepared (I will leave it up to you if you call the role allocation "traditional" or "chauvinist", btw. ;-)

This is basically also how Norouzy et al. try to explain the inconsistencies that become obvious, when you compare the study at hand to previous results:
"This inconsistency may be a result of the subject characteristics and, in particular, age, sex and physical activity, as well as the number of hours of fasting observed during Ramadan, which varies according to geographical location from 11 to 19 h a day." (Norouzy. 2013)
Furthermore, the majority of previous studies included young subjects aged <35 years; thus, limited information is available on subjects of older ages and according to Norouzy et al. their study was the first to "attempted to compare changes in body weight and composition in different ages and sex" (Norouzy. 2013). In view of the existing differences in resting energy expenditure and physical activity this could well explain part of the differences between the studies and the high amounts of "null results" (=no change at all) other scientists reported (Ati.1995; Finch. 1998; Ramadan. 2002; Yucel.2004).
Figure 2: Dietary energy, macronutrient and fibre intakes before and during Ramadan and percentage changes from baseline according to gender; I must warn you though, according to the scientists dietary records were not available from all participants (Norouzy. 2013)
Going back to the study at hand, the data in figure 2 indicates that neither the general trends, nor the age and sex-specific differences can be fully explained by changes in total energy (due to high variability borderline significant only in men, totally insignificant in women) or macronutrient ratios (insignificant in both); an observation the Iranian researchers try to explain by differences in nutrient oxidation and changes in energy expenditure during the fasting period and add:
Overtraining and undereating will have your thyroid hormones plummet within no more than four days (learn more) - would Intermittent Fasting make that worse, or could it - as I suggest in the bottom line - maybe even postpone the onset of plummeting T3 and increasing rT3 levels by allowing you to eat to satiety once a day? Respective studies are missing, but it does not sound totally implausible!?
"A previous study investigating the effect of Ramadan on the abdominal fat distribution by computed tomography found reductions only in the visceral fat tissue area, and only in subjects in their twenties and in women, and attributed this to fat redistribution because no changes in weight were observed (Yucel et al., 2004). Thus, although this remains to be investigated, differences between sexes and ages may be a result of differences in nutrient oxidation and changes in energy expenditure during the fasting period. For example, as shown in healthy women aged 25–39 years, Ramadan fasting induced a significant decline in carbohydrate oxidation and a significant increase of fat oxidation, as well as a decline in diurnal energy expenditure, which may be attributed to the absence of post-prandial thermogenesis during fasting (Ati al., 1995). A reduction of energy expenditure during Ramadan was also reported in another study (Sweileh et al., 1992)." (Norouzy. 2013)
Now, these changes in (1) fatty acid oxidation (Ati. 1995), (2) improvements in visceral fat (questionable whether those occurred in the study at hand that did not observe sign. reductions in waist circumference in any group) and (3) overall energy expenditure would unquestionably be of interested for the average physical culturist, as well and (1) could in fact be one of the reasons that numerous people report great fat loss following respective regimen. After all, one of the major obstacles of translating fatty acid oxidation to fat loss is that the latter must occur in the presence of an energy deficit or the body fat that's getting oxidized on time-point T1 is going to be replenished from the fats, carbs and protein on time-point T2.

Exercise prevents, not amplifies, fasting induced protein degradation. In a 2006 paper, Kasperek et al. report that
"Exercise did prevent the increase in the rate of total protein degradation caused by food restriction, which may have important implications in weight reduction diets." (Kasperek. 2006)
And indeed, any type of fast (even an intermittent one) that is intended to improve body composition would be missing out big time without the exercise component - just keep it to a sane level and focus on muscle preserving strength training.
Energy intake counts: If you remember the recent SuppVersity post on the detrimental effects a caloric deficit can have on the thyroid function in the presence of a high volume training regimen after four days only, it may sound hilarious that the bottom line starts with the words "energy intake counts". However, faced with the fact that a very large energy deficit will stall weight loss, people tend to forget that not being in a minimal energy deficit won't allow you to lose weight either (the whole alternate day fasting regimen is based on the simple fact that 90% of the people won't fully compensate for the caloric deficit on the low calorie = fasting days).

In that intermittent fasting or rather the ingestion of one or two large meals instead of many mini-meals may provide an edge over "classic" dieting as it allows for a daily "feast" that could trick your body to believe that the starvation it experienced earlier in the day was already over. This in turn could delay the metabolic slowdown and rock bottom T3 levels Loucks et al. observed in the female participants of their exercise + dieting trial within no more than 4 days (go back and learn all the details about the Loucks study). If that's the case, we would not have an absolute increase in energy expenditure (see pt. 3, above), but at least a relative one - compared to eating 6 mini square meals.
    • el Ati J, Beji C, Danguir J. Increased fat oxidation during Ramadan fasting in healthy women: an adaptative mechanism for body-weight maintenance. Am J Clin Nutr. 1995 Aug;62(2):302-7.  
    • Frost G, Pirani S. Meal frequency and nutritional intake during Ramadan: a pilot study. Hum Nutr Appl Nutr. 1987 Feb;41(1):47-50.
    • Husain R, Duncan MT, Cheah SH, Ch'ng SL. Effects of fasting in Ramadan on tropical Asiatic Moslems. Br J Nutr. 1987 Jul;58(1):41-8.
    • Kasperek GJ, Conway GR, Krayeski DS, Lohne JJ. A reexamination of the effect of exercise on rate of muscle protein degradation. Am J Physiol. 1992 Dec;263(6 Pt 1):E1144-50. 
    • Leiper JB, Molla AM, Molla AM. Effects on health of fluid restriction during fasting in Ramadan. Eur J Clin Nutr. 2003 Dec;57 Suppl 2:S30-8.
    • Ramadan J. Does fasting during Ramadan alter body composition, blood constituents and physical performance? Med Princ Pract. 2002;11 Suppl 2:41-6. 
    • Singh R, Hwa OC, Roy J, Jin CW, Ismail SM, Lan MF, Hiong LL, Aziz AR. Subjective Perception of Sports Performance, Training, Sleep and Dietary Patterns of Malaysian Junior Muslim Athletes during Ramadan Intermittent Fasting. Asian J Sports Med. 2011 Sep;2(3):167-76.
    • Sweileh N, Schnitzler A, Hunter GR, Davis B. Body composition and energy metabolism in resting and exercising muslims during Ramadan fast. J Sports Med Phys Fitness. 1992 Jun;32(2):156-63. 
    • Trabelsi K, El Abed K, Trepanowski JF, Stannard SR, Ghlissi Z, Ghozzi H, Masmoudi L, Jammoussi K, Hakim A. Effects of ramadan fasting on biochemical and anthropometric parameters in physically active men. Asian J Sports Med. 2011 Sep;2(3):134-44.
    • Yucel A, Degirmenci B, Acar M, Albayrak R, Haktanir A. The effect of fasting month of Ramadan on the abdominal fat distribution: assessment by computed tomography. Tohoku J Exp Med. 2004 Nov;204(3):179-87.