Effects of Ramadan fasting on anthropometric measures, blood pressure and lipid profile among hypertensive patients in Kurdistan region of Iraq

Abstract

Objective: This study was employed to assess the effects of Ramadan fasting on anthropometric measures, blood pressure and lipid profile among hypertensive patients.
Method: This cross-sectional study was conducted among a representative sample, which was selected using a census survey of hypertensive patients (both gender, aged 25-50 years, on regular antihypertensive drugs (Atenolol: 50 mg orally once a day)), during Ramadan month that was falling in April to May 2020. Patients receiving care at Halabja hospital in Kurdistan region of Iraq. All patients were assessed in two phase’s baseline (a week before) and end stage (a week after Ramadan), using anthropometric indices, physical examination, biochemical tests and a structured questionnaire. Statistical analysis was performed using SPSS version 21.
Results: A total of 120 hypertensive patients were included in the study (50% females and 50% males), with a mean age of 37.5±6.6 years. The major finding of our study was the significant decrease in blood pressure (P value < 0.001). Furthermore, the body weight, BMI, and WC of the participants decreased after Ramadan fasting in a significant approach (P value < 0.001 for all). However, for the lipid profile components, the TC, LDL-C, and HDL-C change persisted not statistically significant (P value > 0.05), while only TG decreased drastically after Ramadan fasting (P value < 0.001).
Conclusion: Ramadan fasting could contributes in the improvement of blood pressure and lowers TG levels, body weights, BMI and WC of adult hypertensive patients.

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Introduction
Hypertension and dyslipidemia are each considered biomark-
ers for metabolic syndrome, and predispose to increase the
risk of cardiovascular disease (CVD),1 but the two are seri-
ously altered because their combined effects are multiplied
rather than added.2 It has been confirmed that CVD is the lead-
ing cause of death in the world, and most people with CVD
have a high level of total cholesterol (TC), low-density lipo-
protein cholesterol (LDL-C), and triglyceride (TG) and a low
level of high-density lipoprotein cholesterol (HDL-C).3 In
addition, a positive strong association between blood pressure
Effects of Ramadan fasting on
anthropometric measures, blood pressure,
and lipid profile among hypertensive
patients in the Kurdistan region of Iraq
Halgord Ali M Farag1, Hardi Rafat Baqi2, Syamand Ahmed Qadir2,
Abdel Hamid El Bilbeisi3, Kawa Khwarahm Hamafarj1,
Mahmoud Taleb4 and Amany El Afifi4
Abstract
Objective: This study was employed to assess the effects of Ramadan fasting on anthropometric measures, blood pressure,
and lipid profile among hypertensive patients.
Method: This cross-sectional study was conducted among a representative sample, which was selected using a census
survey of hypertensive patients (both gender, aged 25–50 years, on regular antihypertensive drugs (atenolol: 50 mg orally
once a day)), during Ramadan month that was falling in April to May 2020. The patients were receiving care at Halabja
hospital in the Kurdistan region of Iraq. All patients were assessed in two phase’s baseline (a week before Ramadan) and
end stage (a week after Ramadan), using anthropometric indices, physical examination, biochemical tests, and a structured
questionnaire. Statistical analysis was performed using SPSS version 21.
Results: A total of 120 hypertensive patients were included in the study (50% females and 50% males), with a mean age of
37.5 ± 6.6 years. The major finding of our study was the significant decrease in blood pressure (P < 0.001). Furthermore, the
body weight, body mass index, and waist circumference of the participants decreased after Ramadan fasting in a significant
approach (P < 0.001 for all). However, for the lipid profile components, the total cholesterol, low-density lipoprotein
cholesterol, and high-density lipoprotein cholesterol change persisted not statistically significant (P > 0.05), while only
triglyceride decreased drastically after Ramadan fasting (P < 0.001).
Conclusion: Ramadan fasting could contribute in the improvement of blood pressure and lowers triglyceride levels, body
weight, body mass index, and waist circumference of adult hypertensive patients.
Keywords
Anthropometric measures, blood pressure, Kurdistan, lipid profile, Ramadan fasting
Date received: 5 July 2020; accepted: 22 September 2020
1 Nursing Department, Technical College of Health, Research Center,
Sulaimani Polytechnic University, Sulaimani, Iraq
2
Medical Laboratory Science, Technical College of Applied Sciences,
Research Center, Sulaimani Polytechnic University, Sulaimani, Kurdistan,
Iraq
3
Department of Clinical Nutrition, Faculty of Pharmacy, Al Azhar
University of Gaza, Gaza Strip, Palestine
4Faculty of Pharmacy, Al Azhar University of Gaza, Gaza Strip, Palestine
Corresponding author:
Abdel Hamid El Bilbeisi, Department of Clinical Nutrition, Faculty of
Pharmacy, Al Azhar University of Gaza, Gaza Strip 0097, Palestine.
Email: abed_az@hotmail.com
965780SMO0010.1177/2050312120965780SAGE Open MedicineFarag et al.
research-article2020
Original Article

2 SAGE Open Medicine
(BP) and dyslipidemia has been reported in many epidemio-
logical investigations;4–6 however, the outcome has frequently
been conflicting with the population subgroup7 and other
shows little significant.8 Because of being overweight, change
in lifestyle, physical inactivity, unhealthy diet, and increased
life expectancy, the prevalence of hypertension is anticipated
to increase in developing and developed countries.4
Based on the previous research, there is a growing interest
regarding the health implication of fasting during Ramadan.
The estimated period of fasting time is different and it
depends on the geographical location, starting from dawn to
dusk. During this period, a healthy adult Muslim abstains
from any kind of eating and drinking. Obviously, fasting
influence the body through creating changes in human physi-
ological parameters which may result in a variety of lipid
profile and hypertension.9 Other shows no significant change
before and after intermittent fasting in hypertensive patients
under treatment; this may be due to different lifestyles and
various dietary intakes in addition to duration of fasting.10 To
estimate the beneficial effect of restricted dietary fat and
saturated fat for CVD,11 the effect of fasting has been
reviewed extensively in metabolic regulation and improve-
ment of lipid profile,12,13 and occasional BP.14 Decreased BP
during the fasting period has been reported, but unfortu-
nately, it increased after eating again in a previous study.15 A
part of conflict and few studies regarding the effect of
Ramadan fasting on the hypertensive patient under treat-
ment, no study has investigated the effect of long-term fast-
ing effect during spring in Kurdish Iraqi hypertensive
Muslim patients under treatment. The purpose of this study
was to assess the effects of fasting on anthropometric meas-
ures, BP, and lipid profile in diagnosed hypertensive patients.
Methodology
Study participants
This cross-sectional study was conducted among a representa-
tive sample, which was selected using a census survey of
hypertensive patients on regular antihypertensive drugs (aten-
olol: 50 mg orally once a day), during Ramadan month that
was falling in April to May 2020, with an average fast of
16 ± 1 h and maximum temperature was 42–48°C. Patients
were receiving care at Halabja hospital in the Kurdistan region
of Iraq. All patients were assessed in two phase’s baseline (a
week before Ramadan) and end stage (a week after Ramadan),
using anthropometric indices, physical examination, biochem-
ical tests, and a structured questionnaire. Patients came to the
clinic in the morning for data collection. In addition, all meas-
urements and attempts before and after Ramadan were made
at the same time of the day and under the same conditions.
Furthermore, a pilot study was carried out on 20 patients to
enable the researcher to examine the tools of the study. The
questionnaire and data collection process were modified
according to the results of the pilot study.
Inclusion and exclusion criteria
Eligibility criteria for participants having hypertension were
based on the Joint National Committee (JNC)-7 criteria,16
adults aged 25–50 years, both gender, and living in Halabja
(Kurdistan region of Iraq). Individuals, who were using any
kind of medications except antihypertension drugs (atenolol:
50 mg orally once a day), were not included in this study.
Participants with both types of diabetes, renal problems, his-
tory of bariatric surgery; participants who were taking weight
loss medications; pregnant women; smokers or people who
drink alcohol; and women with menstrual cycle during data
collection were excluded. Furthermore, eligible individuals
who did not follow at least 25 days of fast were also excluded
from the study.
Sample and sampling technique
In the present study, a representative sample was selected
using a census survey as all patients with the inclusion crite-
ria in our hospital were selected for the study. A total of 156
individuals were invited to participate in the current study, of
which 20 individuals did not respond to the invitation and 16
individuals did not meet the inclusion criteria pertaining to
the current study. At the end, a total of 120 patients with
hypertension were included in the present study (60 males
and 60 females).
Biochemical assessments
Fasting blood samples were collected at baseline and at the
end of the holy month of Ramadan intervention after 10 h of
overnight fasting to quantify serum levels of TC (mg/dL), TG
(mg/dL), LDL-C (mg/dL), and HDL-C (mg/dL). The col-
lected blood was allowed to stand for 30 min at room tem-
perature to allow complete clotting and clot retraction.
Samples were then centrifuged at 3500 r/min for 15 min to
extract serum.17The serum was then used to determine the
levels of TC, TG, and HDL-C. In addition, LDL-C was calcu-
lated using the Friedwald formula.18 A Mindray BS-300
chemistry analyzer instrument was used for blood chemistry
analysis.19 The lipid profile components have reference
ranges that are considered normal in clinical practice. In the
present study, the following National Cholesterol Education
Program Adult Treatment Panel III (NCEP-ATP III) cut-off
values were used as the reference: TC < 200 mg/dL,
TG < 150 mg/dL, LDL-C < 100 mg/dL, and HDL-C > 40 mg/
dL in men and >50 mg/dL in women.20,21
Anthropometric measurements
Weight (kg) was measured using a standard scale (seca);
patients were asked to remove their heavy outer cloth, and
weight was measured and recorded to the nearest 0.1 kg.
Height (m) was measured in all patients (patients barefooted

Farag et al. 3
and head upright); the height was reported to the nearest
0.5 cm. Furthermore, a stretch-resistant tape was used for
measuring waist circumference (WC); WC (cm) was meas-
ured at the approximate midpoint between the lower margin
of the last palpable rib and the top of the iliac crest. The body
mass index (BMI) was calculated as weight, divided by
height squared (kg/m2).22
Assessment of BP
BP was measured in the left arm (mm Hg) using a standard
mercury sphygmomanometer with an appropriate cuff size
during each interview (from the baseline to the end of study),
while the patient with an empty bladder was seated after
relaxing for at least 10 min in a quiet environment.23
Statistical analysis
Statistical analysis was performed, using SPSS version 21.
The normality of data was checked using Kolmogorov–
Smirnov and Shapiro–Wilk tests (P > 0.05). The descriptive
statistics of mean, standard deviation, and percentages were
calculated for the entire sample. The differences between
mean were tested by the independent samples t test and
paired sample t test. In this study, a P value less than 0.05
was considered statistically significant.
Results
A total of 120 hypertensive patients (50% females and 50%
males) were included in the study. The anthropometric data of
the study population before Ramadan by sex are shown in
Table 1. The results revealed that the mean age (years) for
male patients was 38.2 ± 6.8 versus 36.9 ± 6.7 for females. In
addition, for the following variables (height and WC), the dif-
ference was statistically significant in both sexes (P < 0.05).
In the present study, all measurements were performed in
two phase’s baseline (a week before Ramadan) and end stage
(a week after Ramadan). The mean of anthropometric meas-
ure in both genders before and after Ramadan is presented in
Table 2. The findings indicated a 3.5-kg decline in weight
(3.9 kg in males and 3.2 kg in females) and a 2.4-cm reduc-
tion in WC (1.9 cm in males and 2.9 cm in females); the
reduction in WC in females was more than that in males, as
well as a 1.4-kg/m2 decline in the BMI (1.4 in males and 1.3
in females). Furthermore, the body weight, BMI, and WC of
the participants decreased after Ramadan fasting in a signifi-
cant approach in both sexes (P < 0.001 for all).
On the other hand, Table 3 shows the effects of Ramadan
fasting on BP and lipid profile. BP either systolic or diastolic
was significantly reduced at the end of fasting in both sexes
(P < 0.001). Also, the TG level significantly decreased dur-
ing Ramadan in both sexes (P < 0.001). Moreover, a reduc-
tion in the average values of TG (190.8 ± 74.9 versus
145.3 ± 38.5) and an increase in LDL-C (138.2 ± 54.9 to
139.3 ± 31.4) were observed at the end of the fast, but the
differences were not statistically significant (P > 0.05). In
addition, there was a non-significant change in HDL-C at the
end of the fast (P > 0.05).
Discussion
To the best of our knowledge, this is the first study, which
shows the effects of Ramadan fasting on anthropometric
measures, BP, and lipid profile among hypertensive patients
in the Kurdistan region of Iraq. The main findings of this
study were the significant decrease in BP, body weight, BMI,
and WC of the participants after Ramadan fasting. However,
the TC, LDL-C, and HDL-C change persisted not statistically
significant, while only TG decreased drastically after
Ramadan fasting. High BP is a key factor in the development
of CVD.24 In the present study, the measurements of systolic
and diastolic BP before and after Ramadan fasting shows a
large decrease for both males and females in a statistically
significant manner. In the literature, results similar to ours are
observed. In a systematic review of five studies, Alinezhad
et al.25 observed a statistically significant change in systolic
BP in three studies, while the other two studies showed non-
significant changes; while for diastolic BP, three of the five
studies showed non-significant change before and after
Ramadan fasting and the other two studies reported a reduc-
tion in diastolic BP after Ramadan.24
As for TG in mg/dL, there is a statistically significant
decrease in the mean value before and after Ramadan fast-
ing, indicating the effectiveness of Ramadan fasting in the
reduction of higher TG levels in hypertensive patients.
Table 1. Anthropometric data before Ramadan.
Variables Total (n = 120) Male (n = 60) Female (n = 60) P value
Age (years) 37.5 ± 6.6 38.2 ± 6.8 36.9 ± 6.7 0.534
Weight (kg) 82.9 ± 15.5 83.3 ± 16.5 82.5 ± 14.9 0.873
Height (m) 1.5 ± 0.0 1.6 ± 0.1 1.5 ± 0.07 0.024
BMI (kg/m2) 32.8 ± 5.1 31.7 ± 5.7 33.9 ± 4.3 0.076
WC (cm) 108.7 ± 10.1 110.0 ± 11.9 107.5 ± 8.05 0.030
BMI: body mass index; WC: waist circumference; SD: standard deviation.
The values are expressed as mean ± SD. The differences between means were tested by using the independent samples t test. A P value less than 0.05
was considered statistically significant.

4 SAGE Open Medicine
Across the literature, many other studies have similar results
with the present study.26,27 The criteria adopted for accepting
of the subjects were strict, and only the pre-diagnosed hyper-
tensive and on-medication patients were included in the final
results of the study. Because of evidence that many drugs
interact with antihypertensive drugs, intake of other medica-
tions may vary the status of BP;25 the pregnancy may also
induce hypertension in many various ways;28 and in the same
way, there is an established relationship between alcohol
intake and hypertension, which points out alcohol intake
elevates BP. However, this association is not yet elusive,29
and for the sake of more accuracy and precession, individu-
als using drugs other than hypertension medications, people
who drink alcohol or smokers, and pregnant women were all
excluded from engagement in the study.
The blood specimens were withdrawn after overnight fast-
ing, as the results of the fasting serum lipid profile test are more
sensitive and reliable for the assessment of CVD.30 Pre-
Ramadan anthropometric measurements of the participants
were taken that might help to determine the risks of high lipid
profile values; literature shows that maintaining normal body
weight may prevent the risk of CVD.31 The population included
Table 3. Effect of Ramadan fasting on blood pressure and lipid profile.a
Variables No. Before Ramadan After Ramadan Changes 95% CI difference P value
SBP (mm Hg) 120 132.3 ± 8.6 123.8 ± 8.2 7.5 ± 7.2 (−) 5.3 to 9.7 0.001
Male 60 134.5 ± 6.7 127.3 ± 6.5 7.3 ± 6.1 (−) 4.6 to 9.9 0.001
Female 60 130 ± 9.8 122.3 ± 9.09 7.3 ± 8.3 (−) 4.06 to 11.4 0.001
DBP (mm Hg) 120 83.4 ± 6.07 76 ± 6.4 7.4 ± 6.5 (−) 5.4 to 9.4 0.001
Male 60 84.3 ± 7.1 77.8 ± 6 6.5 ± 6.4 (−) 3.6 to 9.3 0.001
Female 60 82.5 ± 4.8 74.1 ± 6.3 8.4 ± 6.5 (−) 5.8 to 11.3 0.001
TC (mg/dL) 120 184.2 ± 49.14 181.06 ± 35.6 3.1 ± 30.3 (−) −6.1 to 12.3 0.499
Male 60 189.6 ± 56.7 186.9 ± 34.7 2.8 ± 38.4 (−) −14.3 to 19.8 0.721
Female 60 178.7 ± 40.8 175.3 ± 36.2 3.5 ± 20.2 (−) −5.5 to 12.4 0.445
TG (mg/dL) 120 190.8 ± 74.9 145.3 ± 38.5 45.5 ± 56.1 (−) 28.4 to 62.6 0.001
Male 60 200.5 ± 81.4 152.3 ± 46.4 48.2 ± 60.8 (−) 21.2 to 75.1 0.001
Female 60 181.05 ± 68.4 136.2 ± 27.8 42.8 ± 52.4 (−) 19.6 to 66.03 0.001
HDL-C (mg/dL) 120 35.09 ± 14.5 35.3 ± 11.05 0.3 ± 11.7 (+) −3.8 to 3.3 0.888
Male 60 32.7 ± 10.5 33.04 ± 6.4 0.3 ± 9.07 (+) −4.3 to 3.4 0.901
Female 60 37.5 ± 17.6 37.6 ± 14.07 0.2 ± 14.1 (+) −6.4 to 6.07 0.123
LDL-C (mg/dL) 120 138.2 ± 54.9 139.3 ± 31.4 1.1 ± 39.2 (+) −13.02 to 10.8 0.851
Male 60 140.7 ± 66.4 144.1 ± 32.3 3.5 ± 51.5 (+) −26.3 to 19.4 0.821
Female 60 135.7 ± 41.7 134.5 ± 30.4 1.2 ± 22 (−) −8.5 to 11 0.835
CI: confidence interval; (+): increase; (−): decrease; SBP: systolic blood pressure; DBP: diastolic blood pressure; TC: total cholesterol; TG: triglyceride;
LDL-C: low-density lipoprotein cholesterol; HDL-C: high-density lipoprotein cholesterol.
The values are expressed as mean ± SD.
aThe paired sample t test was used for normally distributed data.
A P value less than 0.05 was considered statistically significant.
Table 2. Effect of Ramadan fasting on anthropometric measure.a
Variables No. Before Ramadan After Ramadan Changes 95% CI
difference
P value
Weight (kg) 120 82.9 ± 15.56 79.4 ± 15.56 3.5 ± 4.9 (−) 2.04–4.9 0.001
Male 60 83.3 ± 16.5 79.4 ± 16.4 3.9 ± 5.5 (−) 1.4–6.3 0.003
Female 60 82.5 ± 14.9 79.4 ± 15.3 3.2 ± 4.3 (−) 1.3–5.06 0.002
BMI (kg/m2) 120 32.9 ± 5.1 31.5 ± 5.3 1.4 ± 1.8 (−) 0.8–1.9 0.001
Male 60 31.7 ± 5.7 30.3 ± 6.01 1.4 ± 1.8 (−) 0.6–2.2 0.001
Female 60 33.9 ± 4.3 32.7 ± 4.4 1.3 ± 1.8 (−) 0.5–2.1 0.003
WC (cm) 120 108.8 ± 10.12 106.3 ± 10.14 2.4 ± 3.3 (−) 1.4–3.4 0.001
Male 60 110 ± 11.9 108 ± 11.9 1.9 ± 3.7 (−) 0.3–3.5 0.020
Female 60 107.5 ± 8.1 104.6 ± 7.8 2.9 ± 2.8 (−) 1.7–4.2 0.001
CI: confidence interval; BMI: body mass index; WC: waist circumference; (+): increase; (−): decrease; SD: standard deviation.
The values are expressed as mean ± SD.
aThe paired sample t test was used for normally distributed data.
A P value less than 0.05 was considered statistically significant.

Farag et al. 5
in the study was overweight, while their weight after Ramadan
diminished in a statistically significant way, which confirms
the effectiveness and dependability of Ramadan fasting and
body weight. The BMI and WC of the participants were meas-
ured as it has been proven that they are conversely correlated
with HDL-C levels and are directly proportional to TG
levels.32The outcome mean BMI and WC values before
Ramadan turned out to be higher than those after Ramadan in a
statistically significant fashion; this reduction came as a result
of the major variations in eating patterns of the people who fast
and lower calorie intake. Generally, the females in the study
were more overweight when comparing their BMI values to
those of males; the reason could be referred to as the fact that
males are more physically active than females. In most of the
literature, there is a positive correlation between BMI and TC,
TG, and LDL-C values.33 While for HDL-C, the correlation to
BMI is inversely related.34 As the body values including weight
and BMIs of the participants have changed during the Ramadan
fasting, a considerable change in lipid profile values is expected
as well. There is a minimal reduction in the mean TC value
after Ramadan fasting, yet such small changes are not statisti-
cally significant as the P value is greater than 0.05. It is note-
worthy to mention that the mean TC values in males are higher
than those in females in both before and after Ramadan fasting.
Similar results of TC and body weight could be observed in
alike studies.35 The LDL-C in mg/dL adopted TC’s character.
Although its mean values were slightly elevated after the fast-
ing, the change was not statistically significant. This slight
elevation in LDL-C results after Ramadan fasting is not seen in
other similar studies; in fact, many other studies show a statisti-
cally significant decrease in LDL-C after Ramadan,26,27 yet, we
observed reciprocal results in our findings. With a slight change
in the mean HDL-C mg/dL value, this variable as well remains
not affected, as the P value for this minimalistic change is not
statistically significant.
The strength of the present study is that this is the first
study, which shows the effects of Ramadan fasting on anthro-
pometric measures, BP, and lipid profile among hypertensive
patients in the Kurdistan region of Iraq. The main limitations
of this study are its cross-sectional design, the causal rela-
tionship could not be determined, and the power analysis for
sample size calculation was not done in this study, and it
limits the generalizability of our results. Further future stud-
ies about the effects of dietary patterns and physical activity
during Ramadan fasting on anthropometric measures includ-
ing “body adiposity index (BAI),” “visceral adiposity index
(VAI),” “Waist-Height Ratio (WHtR),” BP, and lipids profile
among hypertensive patients are required.
Conclusion
We conclude that Ramadan fasting could contribute to the
improvement of BP and lowers TG levels, body weight,
BMI, and WC of adult hypertensive patients in Halabja city
of the Kurdistan region of Iraq.
Acknowledgements
The authors thank the staff and participants in the Halabja hospital
for their important contributions to the study.
Author contributions
H.A.M.F. (principal investigator) collected, analyzed, and inter-
preted the data and wrote the first draft of the manuscript. H.R.B.,
S.A.Q., K.K.H., and M.T. significantly contributed to the study
design and the critical review of the manuscript. A.H.E.B. and
A.E.A. remarkably contributed to the analysis and interpretation of
data and the critical review of the manuscript. All authors approved
the final manuscript.
Declaration of conflicting interests
The author(s) declared no potential conflicts of interest with respect
to the research, authorship, and/or publication of this article.
Ethical approval
The study protocol was approved by the Ethics Committee of
Halabja hospital, centers for control of communicable and non-
communicable diseases (No. 2020-53). Furthermore, a written
informed consent was obtained from the study participants.
Funding
The author(s) received no financial support for the research, author-
ship, and/or publication of this article.
ORCID iD
Abdel Hamid El Bilbeisi https://orcid.org/0000-0001-8870-8326
Supplemental material
Supplemental material for this article is available online.
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