Sage Journals: Discover world-class research

Abstract

This study aimed to carry out a Ramadan observance (RO) on anthropometric, psychosocial, physiological, and postural characteristics of patients with chronic obstructive pulmonary disease (COPD). Twenty COPD patients were evaluated. Tests performed 1 week before Ramadan (C), and during the second (R-2) and the fourth weeks of Ramadan (R-4) included standard anthropometry, spirometry, a quality of life questionnaire (VQ11), a 6-minute walking test (6MWT), measurement of maximal voluntary contraction force of the quadriceps (MVC), Timed Get Up and Go (TUG), Berg Balance Scale (BBS), and Unipedal Stance (UST). During R-2, there were significant decreases in forced vital capacity and forced expiratory volumes, 6MWT distance, MVC, BBS, and UST, with significant increases in TUG and significant changes in VQ11. During R-4, there was some recovery, but all variables remained significantly different from initial control data. To conclude, RO adversely affects pulmonary function, exercise performance, postural balance, and quality of life in COPD, with some recovery by the R-4. Although a number of functional consequences remain to be elucidated, functional losses were insufficient to limit daily living in our sample, but further studies are recommended in those with more severe COPD, paying particular attention to postural disturbances and a possible increase in the risk of falls.

Keywords

chronic obstructive pulmonary disease Ramadan observance pulmonary variables postural balance exercise performance

Introduction

Chronic obstructive pulmonary disease (COPD) is a leading cause of morbidity and mortality worldwide (Vestbo et al., 2013); prevalence is high in Tunisia, with 7.8% and 4.2% of the population in disease Stages 1 and 2, respectively (Daldoul et al., 2013). Patients with COPD show an impaired exercise tolerance, often with severe dyspnea, a decreased ability to participate in the activities of daily living, and a poor health-related quality of life (HRQoL; Vestbo et al., 2013). Exercise is limited by a combination of impaired ventilatory function (Agusti et al., 2003) and skeletal muscle dysfunction (Man et al., 2009), with weakness of the lower limbs (Maltais et al., 2000) and impaired balance (Roig et al., 2011).

The common practice of those observing Ramadan is to have two meals per day: a large meal shortly after sunset and a much lighter one immediately before dawn. Ramadan observance (RO) is characterized by many changes in diet and sleep patterns (Souissi et al., 2007), often with a decrease in the time available for nocturnal sleep (Anis et al., 2009). Studies in athletes have observed altered muscle metabolism (Bouhlel et al., 2006), hormonal changes (Bouhlel, Denguezli, et al., 2008; Bouhlel, Zaouali, et al., 2008), and an impaired physical performance depending on the time of day at which test sessions were performed (Anis et al., 2009; Bouhlel et al., 2013; Meckel et al., 2008).

Sometimes there are disturbances of cognitive function (Tian et al., 2011). The study of Patel et al. (2008) reported postural control impairment in young adults due to momentary lapses of attention after sleep deprivation. Such changes are of particular concern in elderly patients with COPD, as their ability to carry out the activities of daily living may initially be marginal, and any disturbances of balance and cognitive function associated with RO could increase the risk of falls (Laatar et al., 2016).

To 2015, only one study has examined the effects of RO in patients with COPD (Aydin et al., 2014); this report focused almost exclusively on changes in medication use during RO. Most Muslim patients with COPD observe Ramadan (e.g., 93% in Turkey; Aydin et al., 2014), but little is known about the clinical, psychosocial, and physiological effects of such fasting in COPD. The aim of the present study was to analyze the effects of RO on anthropometric, psychosocial, physiological, and postural characteristics in patients with COPD.

Method

Design

The present study was designed as a pilot cross-sectional and experimental study. Observations were made during the Ramadan of 2015 (dates from June 18 to July 16); in Tunisia, the fast had a duration of 16 hr 30 min. The selected variables were measured 3 times: before Ramadan (control or C), during the second week of Ramadan (R-2), and during the last week of Ramadan (R-4). A preliminary familiarization session ensured that participants were habituated to the test protocol. All measurements were completed in the same clinical physiology laboratory, under consistent environmental conditions (temperature: 24 ± 2°C, humidity: 68 ± 3%), and at the same time of day (16:00 p.m.) to avoid circadian effects.

Sample

Participants in this study were 20 male volunteers with COPD from the Farhat Hached Hospital of Sousse, Tunisia, who gave their written and informed consent to take part in a study approved by the local committee for the ethics of human experimentation (The Research Ethics Committee of Farhat Hached Hospital, Sousse; Approval No. 01-2015), in accordance with current legal requirements and the Declaration of Helsinki. Clinically stable individuals with a functional diagnosis of COPD according to the global strategy for the diagnosis, management, and prevention of COPD guideline were selected (Singh et al., 2019; Stage II and III; medication remained unchanged during Ramadan). Smokers, those with cardiovascular or neurological disease, lower extremity musculoskeletal problems, and visual deficits that could affect postural control were excluded.

Patients’ Characteristics

All included patients with COPD had a Ramadan fasting history of minimum 5 years, were in stable condition, and were nonsmokers. A questionnaire was performed among patients’ medical history, type of prescript medication treatment, activities of daily living of each patient, fasting recommendation, sleep pattern, and eating schedules. None of them have a history of fall within the last 6 months. Moreover, they are autonomous, could perform their daily activity by themselves, and have the same sociocultural level. All patients have the same eating schedules and number of sleep hours per night.

Measures

Anthropometric Measurements

Body mass (BM) and height were assessed when patients were lightly clothed. BM was measured with a digital scale (Harpenden balance scale; Holtain Ltd., Crosswell, UK) and standing height was measured by stadiometer (Harpenden portable stadiometer; Holtain Ltd.). Body mass index (BMI) was calculated as BM divided by the square of the height (Pi-Sunyer et al., 1998).

Biceps, triceps, subscapular, and suprailiac were measured in triplicate with Harpenden skinfold caliper (Holtain Ltd.) and mean values were used for further analysis. The body density was estimated from four measurements of skinfold thickness using the Durnin and Womersley (1974) equation (density = 1.1715 − 0.0779 × Log[Σ4 skinfold thickness]; Durnin & Womersley, 1974). The percentage of body fat mass was estimated using Siri’s equation (% fat BM = [4.95 / density − 4.50] × 100; Durnin & Rahaman, 1967). Fat-free mass (FFM) was determined by subtracting fat mass from BM (Buskirk & Mendez, 1984).

Quality of Life Questionnaire (VQ 11)

The VQ11 is a reliable and valid measure of COPD-specific HRQoL (Ninot et al., 2013). The 11 items cover three main components: functional (dyspnea, fatigue, and mobility), psychological (physical confidence, anxiety, depression, and sleep), and social (life project, social life, closeness, and emotional life). A high total score indicates a poor HRQoL (Ninot et al., 2013).

Dietary Intake

Patients recorded meal times and amount of food eaten for 3 days before each session (C, R-2, and R-4), including the last meal before the tests. This was completed by interview using a 24-hr recall method. Dietary records were analyzed for energy intake using Bilnut program (Nutrisoft, Cerelles, France) and food composition tables published by the Tunisian National Institute of statistics (el Ati et al., 1995).

Sleep Evaluation

A questionnaire was used to collect sleep habit data (sleep duration and sleep–wake pattern) from COPD (BaHammam, 2003) and a bridged version of the Horne and Ostberg questionnaire (morningness/eveningness test) was assessed to identify the circadian rhythms. This questionnaire established three behavioral categories (morning type, neither type, and evening type; Horne & Östberg, 1976).

Spirometry

Pulmonary function was tested using a Zan 100 spirometer (Inspire Health GmbH, Germany) according to Respiratory Society recommendations, with data related to Tunisian norms (Ben Saad et al., 2013). The parameters measured were (a) forced vital capacity (FVC), (b) forced expiratory volume in 1 s (FEV_1.0), and (c) the ratio FEV_1.0/FVC%.

6-Minute Walking Test (6MWT)

Exercise performance was assessed by 6MWT (Holland et al., 2014). It performed indoors, along a flat, straight, 30 m walking course with a tiled surface. Chairs were placed out to allow participants to rest if needed (Holland et al., 2014). Dyspnea and tiredness were measured using the modified Borg Scale, a descriptive marker of perceived exertion of breathlessness and lower-limb fatigue graded on a 0 to 10 scale, before and at the end of the test (Mahler & Horowitz, 1994). The heart rate (HR) and the peripheral oxygen saturation (SpO₂) were recorded by oximeter throughout using a portable Spiropalm (COSMED, Rome, Italy). Two trials were performed and the longest 6MWT distance (6MWTD) was recorded (Holland et al., 2014).

Isometric Leg Force Assessment

After a warm-up phase of the leg extensor muscle consisting of 5 min cycling at 60% of maximum HR reached at the end of 6MWT, three maximal voluntary isometric contractions (MVC) were made (the best value was recorded), separated by 5 min rest intervals. The Globus Ergo system (TESYS 1000, Codogne, Italy) was used. Participants sat with 90° hip flexion and 90° knee flexion, with stabilization straps positioned across the chest and the arms crossed over the chest as contractions were made.

Balance Assessment

Three simple tests assessed balance: the Timed get Up and Go (TUG), the Berg Balance Scale (BBS), and the Unipedal stance (UST) test. The TUG score reflects both balance and functional mobility (Podsiadlo & Richardson, 1991). The time taken to stand from a chair, walk a distance of 3 m, turn around, return to the chair, and sit down was recorded (Podsiadlo & Richardson, 1991); each participant completed the test 3 times and the faster time was recorded.

The BBS is a psychometrically robust clinical measurement of balance for older adults. It assesses performance on five levels, from 0 (cannot perform) to 4 (normal performance), with 14 items involving functional balance control, including transfer, turning, and stepping; a perfect score is 56 (Tyson & Connell, 2009).

The UST measures the participant’s ability to stand on his preferred leg. A unipedal stance is maintained for a long as possible. A failure is defined as shifting the stance foot or placing the lifted foot on the floor. The UST was considered normal if the unipedal stance was maintained for 45 s or longer (Hurvitz et al., 2000). Participants were given three trials and the longest time was recorded.

Analysis

Statistical analyses were performed using Statistica for Windows software (version 6.0; Statsoft, Inc., Tulsa, OK, USA). As data normality was confirmed using the Kolmogorov–Smirnov test, results were reported as the mean ± SD. Pulmonary and 6MWT parameters, balance assessment (TUG, BBS, and UST), dietary intake, sleep duration, and the MVC data were analyzed using a one-way repeated measures analysis of variance (ANOVA; three testing periods). The VQ11 questionnaire was analyzed using a two-way ANOVA (three testing periods × four components [functional, psychological, relational, and total]). A post hoc (Tukey) test was performed to further analyze the results. Effects sizes for one-way ANOVA were calculated as eta squared (η², where partial eta squared equals eta squared) and for two-way ANOVA to assess the practical significance of our finding (Lakens, 2013). The level of significance was set at p < .05 throughout.

Results

Table 1 presents the baseline characteristics of patients with COPD.

Table 1.

Baseline Characteristics of Patients With COPD.

Low socioeconomic level	8
Low schooling level	10
Ramadan fasting experience (years)	69 ±1.5
Tobacco history (pack-years)	70 ± 39
Respiratory treatments	Bronchodilators Inhaled corticoid Mucoregulators
Medical histories	Stable hypertension Anemia Arterial fibrillation

Note. COPD = chronic obstructive pulmonary disease.

RO had no significant effect on BM and BMI (Table 2). RO had no significant effect on energy intake (carbohydrate, fat, and protein intake). However, there was a significant decrease (p < .001) in fluid intake during R-2 and R-4 compared with C (Table 1).

Table 2

Patients parameters (Anthropometric, Pulmonary Parameters, Dietary Intake, and Sleep Evaluation) during Ramadan Observance.

	C	R-2	R-4
Age (years)	72.7 ± 4.1
Height (m)	1.69 ± 0.04
BM (kg)	74.3 ± 3.7	74.1 ± 2.9	74.2 ± 3.4
BMI (kg/m²)	25.5 ± 5.5	25.4 ± 5.6	25.2 ± 5
FM (kg)	14.6 ± 1.8	14.5 ± 1.8	14.4 ± 1.8
FFM (kg)	59.8 ± 3.3	59.7 ± 3.0	59.7 ± 2.9
FEV₁ (l)	1.8 ± 0.6	1.5 ± 0.6***	1.6 ± 0.7^£
FEV₁ % (predicted)	56 ± 21	48 ± 22***	54 ± 22^###
FVC (l)	3.1 ± 0.4	2.6 ± 0.5***	2.9 ± 0.4^###
FVC % (predicted)	79 ± 12	66 ± 13***	73 ± 11^££,##
FEV₁/ FVC % (predicted)	56 ± 14	51 ± 14*	55 ± 15^#
Energy intake (MJ/d)	7.66 ± 0,5	7.60 ± 0.5	7.54 ± 0.5
Carbohydrate intake (g/d)	240 ± 35	235 ± 35	233 ± 34
Carbohydrate intake (% of energy)	52.4 ± 5.9	51.7 ± 7.2	51.8 ± 6.6
Fat intake (g/d)	66.7± 10	67.3 ± 11	67.1 ± 10.7
Fat intake (% of energy)	33.0 ± 5.9	34.0 ± 5.8	33.8 ± 6.4
Protein intake (g/d)	66.2 ± 8.7	64.5 ± 10.1	64.6 ± 9.9
Protein intake (% of energy)	14.6 ± 2.4	14.3 ± 2.5	14.4 ± 2.6
Fluid intake (L/d)	2.0 ± 0.2	1.8 ± 0.1***	1.9 ± 0.9^£££
Total sleep (hr)	7.9 ± 0.8	7.0 ± 0.8***	6.9 ± 0.7^£££
Nighttime sleep (hr)	7.4 ± 0.7	4.9 ± 0.6***	4.8 ± 0.7^£££
Nap (hr)	0.6 ± 0.4	2.1 ± 0.5***	2.1 ± 0.5^£££

Note. C = before Ramadan; R-2 = the second week of Ramadan; R-4 = the fourth week of Ramadan; BM = body mass; BMI = body mass index; FM = fat mass; FFM = fat-free mass; FEV₁ = forced expiratory volume in one second; FVC = forced vital capacity.

p < .05. ***p < .001: Significant differences between C and R-2.

p < .05. ^££p < .01. ^£££p < .001: Significant differences between C and R-4.

p < .05. ^##p < .01. ^###p < .001: Significant differences between R-2 and R-4.

Post hoc showed a significant decrease (p < .001) in total and nighttime sleep during R-2 compared with C and a significant increase in nap time (p < .001) during Ramadan (R-2 and R-4) compared with C (Table 2).

Concerning the pulmonary variables, all measures decrease during R-2 relative to C (FEV₁, FEV₁%, and FVC, FVC% [all at p < .001], and FEV₁/FVC% [at p < .05]; Table 2). Values that were already low relative to control period showed a further 15% to 17% decrease during Ramadan. Volumes remained decreased during R-4 (FEV₁ and FEV₁%, p < .05, and FVC, p < .01), although there was a substantial and statistically significant recovery relative to R-2 (FEV₁% and FVC values, p < .01, FVC% and FEV₁/FVC%, p < .05).

All VQ11 components (functional, psychological, relational, total) significantly (p < .001) deteriorated during R-2 and R-4 compared with C, with no significant changes between R-2 and R-4 despite the total change from 39.35 ± 4.42 in R-2 to 38.5 ± 3.22 in R-4 (Table 3).

Table 3.

Quality of life questionnaire data during Ramadan Observance.

		C	R-2	R-4
VQ11 components	Functional score	6.6 ± 1.3	12.5 ± 1.1***	12.5 ± 1.3^£££
	Psychological score	8.0 ± 1.6	14.3 ± 3.0***	14 ± 2.6^£££
	Relational score	7.8 ± 2.4	12.6 ± 2.1***	12.1 ± 1.6^£££
	Total score	22.5 ± 4.0	39.4 ± 4.4***	38.5 ± 3.2^£££

Note. C = before Ramadan; R-2 = the second week of Ramadan; R-4 = the fourth week of Ramadan.

***

p < .001: Significant difference between C and R-2.

£££

p < .001: Significant difference between C and R-4.

A significant decrease of 6MWTD and SpO₂ rest and peak during both R-2 (all at p < .001) and R-4 (all at p < .01) relative to C was demonstrated in Table 4.

Table 4

6-Minute Walking Test parameters during Ramadan Observance.

	C	R-2	R-4
6MWTD (m)	521.6 ± 44.7	485.0 ± 55.1***	502.1 ± 50.3^££,##
SpO₂
Rest	95.4 ± 1.1	94.0 ± 0.9***	94.3 ± 1^££
Peak	90.8 ± 3.3	88.9 ± 3.6***	88.8 ± 3.2^£££
Dyspnea
Rest	1.2 ± 0.7	1.2 ± 0.7	1.3 ± 0.47
Peak	3.3 ± 1.1	3.8 ± 1.1	3.8 ± 1.3
HR
Rest	73 ± 8	73 ± 11	73 ± 12
Peak	111 ± 9	123 ± 9	121 ± 8

Note. C = before Ramadan; R-2 = the second week of Ramadan; R-4 = the fourth week of Ramadan; 6MWTD = 6-minute walking test distance; SpO2 = peripheral oxygen saturation; HR = heart rate.

***

p < .001: Significant difference between C and R-2.

p < .05. ^££p < .01. ^£££p < .001: Significant differences between C and R-4.

p < .01: Significant difference between R-2 and R-4.

The MVC was significantly lower (p < .001) during R-2 (382.89 ± 56.91 N) and R-4 (412.67 ± 59.83 N) compared with C (441.61 ± 64.30 N), although values increased from R-2 to R-4 (p < .001; Figure 1).

Figure 1.

Effect of Ramadan Observance on Maximal Voluntary Contractions Force of the Quadriceps Muscles in Three Testing Phases

A higher TUG values (11.41 ± 0.65 s) were demonstrated during R-2 compared with C (10.30 ± 0.64 s, p < .001), with some recovery (10.49 ± 0.75 s) at R-4 (R-4 vs. R-2, p < .001) (Figure 2). BBS and UST showed significant decreases (p < .001) from C to R-2 (53.25 ± 1.22 score to 48.08 ± 3.06 score in BBS; 44.67 ± 1.54 s to 31.88 ± 6.60 s in UST), with partial recovery at R-4 (50.75 ± 2.18 score, p < .01 and 39.96 ± 5.73 s, p < .001, respectively, in BBS and UST) relative to R-2 (Figure 2).

Figure 2.

Effect of Ramadan Observance on Balance Assessment (Timed Up and Go, Berg Balance Scale, and Unipedal Stance Tests) in Three Testing Phases

Discussion

This study demonstrates that the quality of life and postural and physiological characteristics were all deteriorated in patients with COPD during RO. The afternoon performance of the selected tests was depressed by a further 7% to 15% during the second week of Ramadan. However, there was substantial recovery from this deficit by the fourth week of Ramadan.

From an anthropometric point of view, although life changes related to sleep, diet, and various daily activities would be likely to generate changes in body and/or composition, RO did not show any significant change at the different measuring times (R-2 and R-4) in comparison with baselines values. This finding is in line with some previous studies (Finch et al., 1998; Lamine et al., 2006) and indicates that the food momentary deprivation due to Ramadan can be largely compensated for by staggered energy consumption. However, quality of life was impaired during Ramadan. The VQ11 questionnaire scores (functional, psychological, relational, and total) indicated impairments in R-2 and R-4 compared with C, with no significant difference of scores between R-2 and R-4. Borge et al. (2010) previously reported that breathlessness was associated with depression, anxiety, fatigue and sleeping difficulties, and the deterioration of VQ11 score could be related, at least in part, to the substantial decrease of pulmonary function during the fasting period. Effectively, pulmonary variables showed significant decreases during R-2 and R-4 relative to C. The present study was carried out during summer, and in this context, dehydration and fatigue would have contributed more to changes of pulmonary function than would have been the case during a winter celebration of Ramadan (Fenneni et al., 2014). The induced pulmonary changes would presumably be even greater if a summer celebration of Ramadan was observed at high latitude, as in Canada and Europe. Moreover, the impaired quality of life resulted in a significant shortening of nighttime sleep duration during Ramadan, which is partially offset by the increase in daytime naps. Several studies pointed out the role of subjective fatigue sensation during fasting related in part to sleep loss or disruption of normal sleep patterns and/or dehydration (Leiper et al., 2008; Maughan et al., 2010). Sleep deprivation and altered diet are likely to disturb physiological performance (Phillips et al., 1987; Riley & Thakker-Varia, 1995). Those studies demonstrated that the loss of sleep results in a decline in spirometric performance.

From an aerobic performance point of view, RO showed alterations during the first 2 weeks of fasting. The average maximal oxygen consumption of participants (evaluated with the equation of Ross et al., 2010) decreased by almost 2 mL kg⁻¹ min⁻¹ on the basis of an initial value just under 26 mL kg⁻¹ min⁻¹. Although participants remained substantially above the level of 15 mL kg⁻¹ min⁻¹ where difficulty would have been encountered in undertaking the activities of daily living (Shephard, 2012), a reduction of maximum oxygen consumption over a short period of time is always detrimental to health because it continues throughout life. Moreover, RO showed a reduction of 6MWTD performance during R-2 and R-4 that could potentially be explained by a cumulative dehydration related to decreases in fluid intakes (Fenneni et al., 2014). Alternatively, there may have been a change of metabolism (especially a switch from glycogen to more lipolytic energy use during submaximal effort; Bouhlel et al., 2006, 2013; Meckel et al., 2008) although no nutritional change was observed during Ramadan. In fact, the study of Meckel et al. (2008) indicated that the decrease in performance does not necessary related to changes in caloric intake and sleep hours during the fast.

The decrease in quality of life indices could decrease psychological resources and have a negative impact on performance on the 6MWT test and other scores (Souissi et al., 2007) that require the maximum effort of the participants.

The MVC was significantly lower during R-2 and R-4 than C. The decrease of fluid intakes, associated to sleep loss was observed during RO may influence MVC. The alteration of neuromuscular performance induced by fluid deprivation, with associated dehydration and other metabolic or hormonal changes, could be exacerbated during Ramadan (Ramadan, 2002). Likewise, the shift of circadian rhythms during Ramadan could influence the change in MVC (Anis et al., 2009).

The postural balance measures (TUG, BBS, and UST) showed significant deterioration during Ramadan. This result was already for other population, notably healthy elderly (Laatar et al., 2016). The postural impairment due to Ramadan could be explained, at least in part, by changes in circadian rhythms, including times of meals (Roky et al., 2003) and cumulative sleep deprivation (Laatar et al., 2016; Liu et al., 2001; Nakano et al., 2001) that it induces. Sleep deprivation (quality and duration) and reduction in fluid intakes observed in participants during Ramadan can degrade visual (Gomez et al., 2008), vestibular (Avni et al., 2006) muscular, and nervous functions (Kato et al., 2000) and thus negatively affect the physiological component of the postural function (Laatar et al., 2016). Other psychological impairments such as alertness and concentration, reaction times, and mood state (Roky et al., 2000; Shephard, 2012) could induce disturbance of postural balance during Ramadan (Laatar et al., 2016). Possibly, the central nervous system can modify its functional organization to cope with the constraints of Ramadan (Mulder et al., 2002).

Study Limitations

This study has some limitation that need to be considered. In the present study, we did not include a control group who did not fast because the nonfasting Muslim patients do not avow themselves as nonfasting. As well, there is a need to extend observations to women and to those with more severe COPD, patients who are challenged to undertake the activities of daily living even without fasting. Furthermore, it would be interesting to add a formal measure of motivation to distinguish physiological responses to repeated fasting and dehydration from an unwillingness of fasting patients to make the maximal efforts inherent in most of the test measures that we used.

Conclusion

Overall, RO appears to impair psychosocial, physiological pulmonary function, exercise performance, and postural balance in patients with COPD. The deterioration of function is greatest in the second week of Ramadan, with some correction by the fourth week, a phenomenon noted in other studies of healthy participants. The magnitude of the changes that we have observed is not of clinical concern except to patients who are initially in marginal physical condition. Nevertheless, to the extent that balance is impaired, patients with COPD may face an increased risk of falls if they choose to observe Ramadan.

Footnotes

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.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This study was supported by Faculty of Medicine of Sousse, University of Sousse, Tunisia.

ORCID iD

Marwa Mekki

References

Agusti

Noguera

Sauleda

Sala

Pons

Busquets

(2003). Systemic effects of chronic obstructive pulmonary disease. European Respiratory Journal, 21(2), 347–360.

Anis

Leiper

J. B.

Nizar

Coutts

A. J.

Karim

(2009). Effects of Ramadan intermittent fasting on sports performance and training: A review. International Journal of Sports Physiology and Performance, 4(4), 419–434.

Avni

Barenboim

Azaria

Zadok

Kohen-Raz

Morad

(2006). Brief posturographic test as an indicator of fatigue. Psychiatry and Clinical Neurosciences, 60(3), 340–346.

Aydin

Celik

G. E.

Onen

Z. P.

Yilmaz

Ozdemir

S. K.

Yildiz

Mungan

Demirel

Y. S.

(2014). How do patients with asthma and COPD behave during fasting? Allergologia et Immunopathologia, 42(2), 115–119.

BaHammam

(2003). Sleep pattern, daytime sleepiness, and eating habits during the month of Ramadan. Sleep and Hypnosis, 5, 165–174.

Ben Saad

El Attar

M. N.

Hadj Mabrouk

Ben Abdelaziz

Abdelghani

Bousarssar

Limam

Maatoug

Bouslah

Charrada

Rouatbi

. (2013). The recent multi-ethnic global lung initiative 2012 (GLI2012) reference values don’t reflect contemporary adult’s North African spirometry. Respiratory Medicine, 107, 2000–2008.

Borge

C. R.

Wahl

A. K.

Moum

(2010). Association of breathlessness with multiple symptoms in chronic obstructive pulmonary disease. Journal of Advanced Nursing, 66(12), 2688–2700. https://doi.org/10.1111/j.1365-2648.2010.05447.x

Bouhlel

Denguezli

Zaouali

Tabka

Shephard

R. J.

(2008). Ramadan fasting’s effect on plasma leptin, adiponectin concentrations, and body composition in trained young men. International Journal of Sport Nutrition and Exercise Metabolism, 18(6), 617–627.

Bouhlel

Salhi

Bouhlel

Mdella

Amamou

Zaouali

Mercier

Bigard

Tabka

Zbidi

Shephard

R. J.

(2006). Effect of Ramadan fasting on fuel oxidation during exercise in trained male rugby players. Diabetes & Metabolism, 32(6), 617–624.

10.

Bouhlel

Zaouali

Miled

Tabka

Bigard

Shephard

(2008). Ramadan fasting and the GH/IGF-1 axis of trained men during submaximal exercise. Annals of Nutrition and Metabolism, 52(4), 261–266.

11.

Bouhlel

Shephard

R. J.

Gmada

Aouichaoui

Peres

Tabka

Bouhlel

(2013). Effect of Ramadan observance on maximal muscular performance of trained men. Clinical Journal of Sport Medicine, 23(3), 222–227.

12.

Buskirk

E. R.

Mendez

(1984). Sports science and body composition analysis: Emphasis on cell and muscle mass. Medicine & Science in Sports & Exercise, 16(6), 584–595.

13.

Daldoul

Denguezli

Jithoo

Gnatiuc

Buist

Burney

Tabka

Harrabi

(2013). Prevalence of COPD and tobacco smoking in Tunisia—Results from the BOLD Study. International Journal of Environmental Research and Public Health, 10(12), 7257–7271.

14.

Durnin

J. V.

Rahaman

M. M.

(1967). The assessment of the amount of fat in the human body from measurements of skinfold thickness. British Journal of Nutrition, 21(3), 681–689. https://doi.org/10.1079/bjn19670070

15.

Durnin

J. V.

Womersley

(1974). Body fat assessed from total body density and its estimation from skinfold thickness: Measurements on 481 men and women aged from 16 to 72 years. British Journal of Nutrition, 32(1), 77–97. https://doi.org/10.1079/bjn19740060

16.

el Ati

Beji

Danguir

. (1995). Increased fat oxidation during Ramadan fasting in healthy women: An adaptative mechanism for body-weight maintenance. American Journal of Clinical Nutrition, 62(2), 302–307. https://doi.org/10.1093/ajcn/62.2.302

17.

Fenneni

M. A.

Latiri

Aloui

Rouatbi

Saafi

M. A.

Bougmiza

Chamari

Ben Saad

(2014). Effects of Ramadan on physical capacities of North African boys fasting for the first time. Libyan Journal of Medicine, 9, 25391. https://doi.org/10.3402/ljm.v9.25391

18.

Finch

G. M.

Day

J. E.

Razak Welch

D. A.

Rogers

P. J.

(1998). Appetite changes under free-living conditions during Ramadan fasting. Appetite, 31(2), 159–170.

19.

Gomez

Patel

Berg

Magnusson

Johansson

Fransson

(2008). Effects of proprioceptive vibratory stimulation on body movement at 24 and 36 h of sleep deprivation. Clinical Neurophysiology, 119(3), 617–625.

20.

Holland

A. E.

Spruit

M. A.

Troosters

Puhan

M. A.

Pepin

Saey

McCormack

M. C.

Carlin

B. W.

Sciurba

F. C.

Pitta

Wanger

MacIntyre

Kaminsky

D. A.

Culver

B. H.

Revill

S. M.

Hernandes

N. A.

Andrianopoulos

Camillo

C. A.

Mitchel

K. E.

. . . Singh

S. J.

(2014). An official European Respiratory Society/American Thoracic Society technical standard: Field walking tests in chronic respiratory disease. European Respiratory Journal, 44(6), 1428–1446. https://doi.org/10.1183/09031936.00150314

21.

Horne

J. A.

Östberg

(1976). A self-assessment questionnaire to determine morningness-eveningness in human circadian rhythms. International Journal of Chronobiology, 4, 97–110.

22.

Hurvitz

E. A.

Richardson

J. K.

Werner

R. A.

Ruhl

A. M.

Dixon

M. R.

(2000). Unipedal stance testing as an indicator of fall risk among older outpatients. Archives of Physical Medicine and Rehabilitation, 81(5), 587–591.

23.

Kato

Phillips

B. G.

Sigurdsson

Narkiewicz

Pesek

C. A.

Somers

V. K.

(2000). Effects of sleep deprivation on neural circulatory control. Hypertension, 35(5), 1173–1175.

24.

Laatar

Borji

Baccouch

Zahaf

Rebai

Sahli

(2016). Effects of Ramadan fasting on postural balance and attentional capacities in elderly people. The Journal of Nutrition, Health & Aging, 20(5), 553–560.

25.

Lakens

(2013). Calculating and reporting effect sizes to facilitate cumulative science: A practical primer for t-tests and ANOVAs. Frontiers in Psychology, 4, 863. https://doi.org/10.3389/fpsyg.2013.00863

26.

Lamine

Bouguerra

Jabrane

Marrakchi

Rayana

Slama

Gaigi

(2006). Food intake and high density lipoprotein cholesterol levels changes during Ramadan fasting in healthy young subjects. La Tunisie Médicale, 84(10), 647–650.

27.

Leiper

J. B.

Junge

Maughan

R. J.

Zerguini

Dvorak

(2008). Alteration of subjective feelings in football players undertaking their usual training and match schedule during the Ramadan fast. Journal of Sports Sciences, 26(Suppl. 3), S55–S69. https://doi.org/10.1080/02640410802538176

28.

Liu

Higuchi

Motohashi

(2001). Changes in postural sway during a period of sustained wakefulness in male adults. Occupational Medicine, 51(8), 490–495.

29.

Mahler

D. A.

Horowitz

M. B.

(1994). Perception of breathlessness during exercise in patients with respiratory disease. Medicine & Science in Sports & Exercise, 26, 1078–1081.

30.

Maltais

LeBlanc

Jobin

Casaburi

(2000). Peripheral muscle dysfunction in chronic obstructive pulmonary disease. Clinics in Chest Medicine, 21(4), 665–677.

31.

Man

D.-C.

Kemp

Moxham

Polkey

M. I.

(2009). Exercise and muscle dysfunction in COPD: Implications for pulmonary rehabilitation. Clinical Science, 117(8), 281–291.

32.

Maughan

Fallah

Coyle

(2010). The effects of fasting on metabolism and performance. British Journal of Sports Medicine, 44(7), 490–494.

33.

Meckel

Ismaeel

Eliakim

(2008). The effect of the Ramadan fast on physical performance and dietary habits in adolescent soccer players. European Journal of Applied Physiology, 102(6), 651–657.

34.

Mulder

Zijlstra

Geurts

(2002). Assessment of motor recovery and decline. Gait & Posture, 16(2), 198–210.

35.

Nakano

Araki

Michimori

Inbe

Hagiwara

Koyama

(2001). Nineteen-hour variation of postural sway, alertness and rectal temperature during sleep deprivation. Psychiatry and Clinical Neurosciences, 55(3), 277–278.

36.

Ninot

Soyez

Préfaut

(2013). A short questionnaire for the assessment of quality of life in patients with chronic obstructive pulmonary disease: Psychometric properties of VQ11. Health and Quality Life Outcomes, 11, 179. https://doi.org/10.1186/1477-7525-11-179

37.

Patel

Gomez

Berg

Almbladh

Lindblad

Petersen

Magnusson

Johansson

Fransson

P.-A.

(2008). Effects of 24-h and 36-h sleep deprivation on human postural control and adaptation. Experimental Brain Research, 185(2), 165–173.

38.

Phillips

B. A.

Cooper

K. R.

Burke

T. V.

(1987). The effect of sleep loss on breathing in chronic obstructive pulmonary disease. Chest, 91(1), 29–32.

39.

Pi-Sunyer

Becker

Bouchard

Carleton

Colditz

Dietz

Foreyt

J. P.

Garrison

R. J.

Grundy

S. M.

Hansen

(1998). Clinical guidelines on the identification, evaluation, and treatment of overweight and obesity in adults: Executive summary. American Journal of Clinical Nutrition, 68(4), 899–917.

40.

Podsiadlo

Richardson

(1991). The timed “Up & Go”: A test of basic functional mobility for frail elderly persons. Journal of the American Geriatrics Society, 39(2), 142–148.

41.

Ramadan

(2002). Does fasting during Ramadan alter body composition, blood constituents and physical performance? Medical Principles and Practice, 11(Suppl. 2), 41–46.

42.

Riley

D. J.

Thakker-Varia

(1995). Effect of diet on lung structure, connective tissue metabolism and gene expression. The Journal of Nutrition, 125(Suppl_6), 1657S–1660S.

43.

Roig

Eng

J. J.

MacIntyre

D. L.

Road

FitzGerald

Burns

Reid

(2011). Falls in people with chronic obstructive pulmonary disease: An observational cohort study. Respiratory Medicine, 105(3), 461–469.

44.

Roky

Chapotot

Benchekroun

M. T.

Benaji

Hakkou

Elkhalifi

Buguet

(2003). Daytime sleepiness during Ramadan intermittent fasting: Polysomnographic and quantitative waking EEG study. Journal of Sleep Research, 12(2), 95–101.

45.

Roky

Iraki

HajKhlifa

Ghazal

N. L.

Hakkou

(2000). Daytime alertness, mood, psychomotor performances, and oral temperature during Ramadan intermittent fasting. Annals of Nutrition and Metabolism, 44(3), 101–107.

46.

Ross

R. M.

Murthy

J. N.

Wollak

I. D.

Jackson

A. S.

(2010). The six minute walk test accurately estimates mean peak oxygen uptake. BMC Pulmonary Medicine, 10(1), 31.

47.

Shephard

R. J.

(2012). The impact of Ramadan observance upon athletic performance. Nutrients, 4(6), 491–505.

48.

Singh

Agusti

Anzueto

Barnes

P. J.

Bourbeau

Celli

B. R.

Criner

G. J.

Frith

Halpin

D. M. G.

Han

López Varela

M. V.

Martinez

Montes

Oca

Papi

Pavord

I. D.

Roche

Sin

D. D.

Stockley

Vestbo

Wedzicha

J. A.

Vogelmeier

(2019). Global strategy for the diagnosis, management, and prevention of chronic obstructive lung disease: The GOLD science committee report 2019. European Respiratory Journal, 53(5), 1900164.

49.

Souissi

Sahli

Tabka

Dogui

Ati

Davenne

(2007). Effect of Ramadan on the diurnal variation in short-term high power output. Chronobiology International, 24(5), 991–1007.

50.

Tian

H.-H.

Aziz

A.-R.

Png

Wahid

M. F.

Yeo

Png

A.-L. C.

(2011). Effects of fasting during Ramadan month on cognitive function in Muslim athletes. Asian Journal of Sports Medicine, 2(3), 145.

51.

Tyson

Connell

(2009). How to measure balance in clinical practice. A systematic review of the psychometrics and clinical utility of measures of balance activity for neurological conditions. Clinical Rehabilitation, 23(9), 824–840.

52.

Vestbo

Hurd

S. S.

Agustí

A. G.

Jones

P. W.

Vogelmeier

Anzueto

Barnes

P. J.

Fabbri

L. M.

Martinez

F. J.

Nishimura

Stockley

R. A.

Sin

D. D.

Rodriguez-Roisin

(2013). Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease: GOLD executive summary. American Journal of Respiratory and Critical Care Medicine, 187(4), 347–365.

Anthropometric,Psychosocial,Physiological,and Postural Observances During Ramadan in Men With Chronic Obstructive Pulmonary Disease

Abstract

Keywords

Introduction

Method

Design

Sample

Patients’ Characteristics

Measures

Anthropometric Measurements

Quality of Life Questionnaire (VQ 11)

Dietary Intake

Sleep Evaluation

Spirometry

6-Minute Walking Test (6MWT)

Isometric Leg Force Assessment

Balance Assessment

Analysis

Results

Discussion

Study Limitations

Conclusion

Footnotes

Declaration of Conflicting Interests

Funding

ORCID iD

References