THE EFFECT OF FASTING IN RAMADAN ON THE VALUES

AND INTERRELATIONS BETWEEN BIOCHEMICAL, COAGULATION

AND HEMATOLOGICAL FACTORS
Nizal Sarraf-Zadegan, MD; Mahmood Atashi, MD; Gholam A. Naderi, PhD;
Abdoul M. Baghai, MD; Sedighe Asgary, PhD; Mohammad R. Fatehifar, MS;
Hossien Samarian, MS; Maryam Zarei, BS

Background: The possible consequences of the long intermittent fasting schedule during Ramadan (one month
of food and water intake limited to night hours, a practice that is followed by the majority of the Muslims
worldwide) on certain biochemical constituents or coagulation variables have not been extensively documented.
Patients and Methods: During the month of Ramadan and two months after, we monitored the concentration
of different plasma lipoproteins, lipoprotein (a) [Lp(a)], apoproteins A1 and B, fibrinogen, factor VII activity
and some selected hematological factors in 50 healthy subjects who were employees of institutes related to the
Isfahan University of Medical Sciences and aged between 30 and 45 years. The effect of fasting in Ramadan on
the relationship between biochemical and coagulation variables was also investigated.
Results: The values of apoprotein B, Lp(a) and low-density lipoprotein cholesterol (LDL-C)/high-density
lipoprotein cholesterol (HDL-C) ratio were significantly decreased during Ramadan (P<0.05), while total
cholesterol (Tot-C), triglycerides (TG), LDL-C, HDL-C and fasting blood glucose did not change during that
month. Among coagulation and hematological factors, fibrinogen level and factor VII activity were significantly
decreased during the month (P<0.05). Results also indicated a significant positive association between
fibrinogen level and Lp(a), factor VII activity and Tot-C, LDL-C, TG and Apo B during Ramadan.
Conclusion: Our findings contribute to a better understanding of previous reports, as the metabolic and
coagulation changes that are considered as atherosclerosis risk factors are counterbalanced during Ramadan.
Ann Saudi Med 2000;20(5-6):377-381.
Key Words: Ramadan, fasting, blood lipids, fibrinogen, factor VII

During the holy month of Ramadan (the ninth lunar month

of the Muslim year), it is obligatory for all adult Muslims
to abstain from food, drink and smoking each day from
dawn to sunset. Usually, the quality of food and eating
patterns change to the consumption of more carbohydrates
and sweet foods, mainly in the form of two large meals at
dawn and sunset. Several studies have reported on the
physiological effects of Ramadan, especially concerning
changes in blood pressure, lipids, apoproteins, fasting
blood sugar (FBS), hormones and other biochemical
parameters.1-8 Other reports have attempted to study the
effect of fasting during that month on the values of certain
hemostatic, fibrinolytic, platelet aggregation and
coagulation factors,9-10 however, the association between
biochemical factors such as apoproteins, lipoprotein (a)
[Lp(a)] and coagulation factors such as fibrinogen or factor
VII, an important interrelationship between some
atherosclerotic risk factors that have been previously
reported,11-16 have not yet been studied during the month of
Ramadan.
From the Isfahan Cardiovascular Research Center, Isfahan, Iran.

Address reprint requests and correspondence to Dr. Sarraf-Zadegan:

Isfahan Cardiovascular Research Center, PO Box 81465-1148, Isfahan, Iran.
E-mail: n.sarraf@dr.com.
Accepted for publication 29 July 2000. Received 3 January 2000.

We conducted this study in the month of Ramadan on a

healthy sample of Iranian adults to investigate the effect of
chronic, intermittent fasting on the values of some
biochemical, coagulation and hemostatic factors which are
considered probable risk factors for ischemic heart
diseases, as well as the interrelations between these
parameters.
Patients and Methods
Fifty adult employees of institutes related to Isfahan
University of Medical Sciences were identified by simple
random sampling. The study was conducted on the 26th
day of the month and repeated two months later. The
subjects (22 males and 28 females) were aged between 30
and 45 years and were fasting for the whole month. They
were found to be healthy on general medical examination
and none was receiving any medication affecting the
studied parameters.
Histories were taken and some anthropometric
variables were identified. Blood pressure was measured
Annals of Saudi Medicine, Vol 20, Nos 5-6, 2000

377

SARRAF-ZADEGAN ET AL

according to the technique described by WHO.17 Blood

samples were taken on the 26th day of Ramadan at 4 p.m.,
then two months later, after 12 hours of fasting. All blood
samples were sent to the Central Laboratory of Isfahan
Cardiovascular
Research
Center.
Hematological
parameters were estimated on fresh blood using Cell
Counter AL820. Clotting time (CT) and bleeding time
(BT) were measured using Lee White method.
Prothrombin time (PT) and partial thromboplastin time
(PTT) were estimated using turbidimetric methods by
Neoplastin Ciplus and C.K. Prest kits, respectively.
Fibrinogen was measured by turbidimetric method using
coagulometer Cascade M4 and Fibri-Prest Automate kits.
Plasma factor VII activity (%) was assessed with a onestage assay. Test plasma was added to plasma deficient in
factor VII, and the clotting time was measured, then factor
VII activity was calculated by reference to a standard
graph produced by testing dilution of a normal human
plasma.
The blood samples were also analyzed for FBS, plasma
triglycerides (TG), total cholesterol (Tot-C) and highdensity lipoprotein (HDL-C) by enzymatic method using
Merck reagent kits and Elan 2000 autoanalyser. LDL-C
was calculated by the Friedewald formula18: low-density
lipoprotein (LDL-C)=Tot-C-(TG/5+HDL-C). Lipoprotein
(a) [Lp(a)] was measured by an ELISA method using
Macro Lp(a) kits. A turbidimetric immunoassay was used
for determining apolipoproteins A1 and B by kits from
Sigma. Reference samples were created at the start of the
study and included in each days analysis to check
laboratory variation. For quality control, Isfahan
Cardiovascular Research Center Laboratory meets the
criteria of the central standard laboratory of the Ministry of
Health in Iran. Also the samples for blood lipids were sent
to the Central Laboratory, St. Rafael University,
Department of Epidemiology, Belgium, under different
numbers unknown to the laboratory, and the highly
significant correlation between the results from the two
laboratories allowed us to use the results for international
comparison.
All calculations were done using the SPSS-V6
statistical software package (the system for statistics) for
analysis of the data. All data were expressed as meanSD.
Comparisons between means observed during and after
Ramadan were tested using paired t-test. The data within
each phase were also examined using Pearsons r
correlation analysis to find the relationship between the
studied variables. Coagulation and hemostatic factors were
used as dependent variables and biochemical parameters
were used as the independent ones. All differences were
considered significant at P<0.05.
Results
FBS, Tot-C, LDL-C, HDL-C, Tot-C/HDL-C ratio, TG
and Apo A1 showed no significant changes during
378

Annals of Saudi Medicine, Vol 20, Nos 5-6, 2000

Ramadan or two months later (Table 1), however, the

values of Lp(a), Apo B and LDL-C/HDL-C ratio were
significantly decreased during fasting in Ramadan
(P<0.05) (Table 1). Although Apo A1 was increased
during Ramadan, this change was not significant (P>0.05).
Table
2
gives
the

TABLE 1. The levels of some biochemical variables measured during

and 2 months after Ramadan (meanSD).
Biochemical variables
During Ramadan
After Ramadan
P-value*
Tot-C (mmol/L)
5.54 1.06
5.9 1.43
0.16
LDL-C (mmol/L)
3.64 0.78
3.58 0.87
0.54
HDL-C (mmol/L)
1.08 0.24
1.09 0.54
0.91
LDL-C/HDL-C
3.29 0.86
4.22 2.65
0.03
Tot-C/HDL-C
5.32 1.42
6.58 3.84
0.05
TG (mmol/L)
2.56 2.54
2.9 2.6
0.11
Lp(a) (mg/dL)
9.0 8.16
14.29 11.17
0.03
Apo-A1 (mg/dL)
152.5 63.9
148.24 15.31
0.58
Apo-B (mg/dL)
83.18 13.67
109.93 32.38
0.00
FBS (mmol/L)
5.1 0.62
5.4 1.18
0.08
SD=standard deviation; *differences between results were analyzed using
paired t-test.
TABLE 2. Values of hematological and coagulation factors during and
2 months after Ramadan (meanSD).
Factors
During Ramadan
After Ramadan
P-value*
Hb (g/dL)
13.607 1.54
14.11 1.58
0
Hct (%)
40.92 4.09
42.15 4.78
0
RBC (x1012/L)
4.42 0.565
4.89 0.687
0
WBC (x109/L
5.86 1.42
5.611.139
0.13
Plt (x109/L)
240.29 43.84
200.65 46.051
0
PTT (S)
28.88 3.48
29.45 3.67
026
PT (S)
11.96 0.71
12.57 0.89
0
BT (min)
4.19 1.7
4.15 1.07
0.88
CT (min)
10.7 3.85
11 3.34
0.72
Fib (mg/dL)
259.23 64.98
299.38 75.92
0
FVII activity (%)
111.43 27.31
124.24 32.65
0.04
SD=standard deviation; *difference between results were analyzed using
paired t-test.
TABLE 3. Correlations among fibrinogen, factor VII activity and some
biochemical parameters during and 2 months after Ramadan.
Biochemical parameters Pearsons r
Pearsons r P-value
P-value
Fibrinogen
During Ramadan
After Ramadan
Tot-C (mmol/L)
0.19
0.16
0.11
0.49
TG (mmol/L)
0.15
0.29
0.09
0.56
LDL-C (mmol/L)
0.26
0.09
0.17
0.29
HDL-C (mmol/L)
0.01
0.93
0.06
0.69
Tot-C/HDL-C
0.14
0.32
0.20
0.21
Lp (a) (mg/dL)
0.31
0.04
0.16
0.39
Apo A1(mg/dL)
0.07
0.76
0.32
0.03
Apo B (mg/dL)
0.15
0.36
0.02
0.87
Factor VII activity
During Ramadan
After Ramadan
Tot-C (mmol/L)
0.39
0.01
0.43
0.00
TG (mmol/L)
0.31
0.02
0.24
0.12
LDL-C (mmol/L)
0.45
0.00
0.15
0.35

EFFECT OF FASTING

HDL-C (mmol/L)
Tot-C/HDL-C
Lp (a) (mg/dL)
Apo A1 (mg/dL)
Apo B (mg/dL)

0.08
0.39
0.01
0.25
0.33

0.53
0.01
0.95
0.27
0.04

0.28
0.13
0.01
0.20
0.37

0.07
0.38
0.93
0.18
0.81

TABLE 4. Correlations among prothrombin time, partial thromboplastin

time and some biochemical parameters during and 2 months after
Ramadan.
Biochemical parameter Pearsons r
Pearsons r P-value
P-value
Prothrombin time
During Ramadan
After Ramadan
Tot-C (mmol/L)
0.18
0.21
0.15
0.04
TG (mmol/L)
0.23
0.09
0.11
0.46
LDL-C (mmol/L)
0.29
0.05
0.18
0.26
HDL-C (mmol/L)
0.06
0.66
0.25
0.11
Tot-C/HDL-C
0.18
0.19
0.29
0.06
Lp (a) (mg/dL)
0.14
0.37
0.02
0.88
Apo A1 (mg/dL)
0.08
0.71
0.39
0.01
Apo B (mg/dL)
0.03
0.83
0.05
0.74
Partial thromboplastin time
During Ramadan
After Ramadan
Tot-C (mmol/L)
0.12
0.39
0.17
0.27
TG (mmol/L)
0.23
0.09
0.37
0.01
LDL-C (mmol/L)
0.04
0.75
0.06
0.71
HDL-C (mmol/L)
0.01
0.91
0.31
0.04
Tot-C/HDL-C
0.06
0.64
0.39
0.01
Lp (a) (mg/dL)
0.35
0.82
0.06
0.93
Apo A1 (mg/dL)
0.14
0.53
0.32
0.03
Apo B (mg/dL)
0.02
0.92
0.08
0.58

values regarding hematological and coagulation

parameters during and after Ramadan. The mean levels of
all these variables (except WBC count, PTT, BT and CT)
showed significant changes when compared with the
fasting period in Ramadan and two months later (P<0.05).
There was a significant fall in fibrinogen level and factor
VII activity during the Ramadan fasting period (P<0.05)
(Table 2).
The correlation between certain hematological and
coagulation factors as dependent variables and biochemical
parameters as independent variables during and after
Ramadan is presented in Tables 3 and 4. While no
significant correlation was observed between fibrinogen
level and Lp(a) after Ramadan, this correlation was
statistically significant during that month (P<0.05). The
relationship between factor VII activity and Tot-C, TG,
LDL-C, Tot-C/HDL-C ratio and ApoB during Ramadan
was statistically significant, but these correlations were not
significant after Ramadan, except for Tot-C. From Table 4,
it appears that there were no significant relationships
between PT or PTT and the selected biochemical variables
during that month.
Ramadan fasting reduced blood pressure significantly.
Both systolic and diastolic blood pressures decreased,
104.514.7 mm Hg during Ramadan vs. 11311.3 mm Hg

after Ramadan, and 64.515.9 mm Hg during Ramadan

vs. 75.59.9 mm Hg after Ramadan, respectively (P<0.05).
Discussion
During the month of Ramadan, Muslims worldwide are
obliged to fast during daytime hours, and restrict food and
drink intake to the period after sunset. People may alter
their sleeping habits and stay awake most of the night.
Smoking is limited to night time only.
The most common risk factors associated with
increased risk of atherosclerotic heart disease or stroke are
abnormalities of lipids, hypertension, smoking and some
coagulation and hemostatic factors that have been
prevalent among our population.19 The most common
causes of mortality in our country are circulatory diseases,
mainly coronary artery disease (CAD).20 We evaluated the
effect of chronic, intermittent fasting during Ramadan,
which is different from acute fasting (morning vs. sunset)
on the values of certain CAD risk factors and the
association/relationship between these risk factors during
and after fasting in Ramadan.
The main findings noted in this report were significant
changes during Ramadan fasting of Lp(a), Apo B level,
LDL-C/HDL-C ratio, fibrinogen levels and factor VII
activity, in the absence of changes of total-C, LDL and
HDL-C and TG levels (Tables 1 and 2). To the best of our
knowledge, few reports have been done on the effects of
Ramadan fasting on the levels of Lp(a), fibrinogen, and
factor VII activity, even though there are numerous studies
reporting similar effects of Ramadan fasting on plasma
lipids and lipoproteins.4-5,7 Some studies have also reported
increased levels of serum cholesterol,1-3,21-23 or
triglycerides2-3,24 at the end of Ramadan. These
discrepancies may be explained by different food habits in
particular populations, however, it is possible that the
varying results may be due to the different seasons during
which Ramadan takes place. Two other factors also play a
part. First, previous studies have shown that serum
cholesterol was significantly higher when the daily food
intake was served as one large meal instead of when it was
divided into small meals.21-22,24 The second factor is the
type of food consumed during Ramadan, as there is a
tendency towards increased intake of carbohydrate (mainly
sucrose, especially to break the fast and during the night)
and fat. One of the studies conducted in Iran reported no
change in serum lipids and FBS.25 The high intake of
carbohydrates, especially sweetened foods, may explain the
insignificant change in FBS that was observed in our study
(Table 1). The present findings of apoprotein changes
during and after Ramadan are in partial agreement with
previous studies, which observed an increase in the level of
Apo A17 and decreased levels of Apo C-11 and C111.2 We
also observed a significant fall in Apo B (Table 1). This
finding has not been previously investigated.

Annals of Saudi Medicine, Vol 20, Nos 5-6, 2000

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SARRAF-ZADEGAN ET AL

We also measured Lp(a) to clarify its changes during

and after Ramadan fasting. Although the concentrations of
Lp(a) in the plasma vary widely between individuals,
attributable to the Apo(a) gene, the levels within an
individual appear to remain remarkably constant,26-27 and
the interesting finding in this study was the significant
reduction in Lp(a) during Ramadan fasting. With regards
to the mechanism, although it was difficult to interpret, it
was suggested that this result might be explained by
changes in several factors besides fasting, such as lifestyle
habits. These include changes in daily activities and
working hours, sleeping habits, complete smoking
cessation from dawn to sunset, etc.
Other findings of this report were the changes in
coagulation and hematological factors noted during
Ramadan (Table 2). Hematocrit was not increased,
although other studies showed some degree of
hemoconcentration,3 which may be related to the time of
study, which was probably in winter. The time of blood
collection may also be a determining factor. Bleeding and
clotting times did not change, while platelet count was
significantly increased (Table 2). Aybak et al.28 and Kordy
and Gader9 have reported different results regarding the
Ramadan effect on these variables. Prothrombin time
showed a significant decrease (though that was not
supported by the factor VII data) (Table 2). Factor VII and
fibrinogen levels were significantly decreased during
Ramadan. Whether these changes are attributable to the
effect of fasting or not is still a matter of discussion. For a
better understanding of these findings, further studies with
a larger sample size are suggested.
Our finding of decreased systolic and diastolic blood
pressure during Ramadan is explained by the reduced fluid
intake and disturbance in fluid balance observed during the
fasting periods of that month.
Among the main objectives of this study was the impact
of fasting during Ramadan on the bodys biochemical,
coagulation and hematological balance. Epidemiological
data have shown that both hyperglycemia and
hyperlipidemia can modify the hemostatic balance,
favoring the development and clinical complications of
atherothrombosis.29-36 Thus, dietary fat appears to
influence both the atherosclerotic and thrombogenic
components of coronary heart disease.
The results presented in Table 3 agreed with other
studies regarding the association between total and LDL
cholesterol, triglycerides, Apo B with factor VII,29-33 an
inter-relationship which potentiates the development or
progression of coronary artery disease. However, the most
important finding is the effect of Ramadan fasting on the
association between Lp(a) and fibrinogen level (Table 3). It
is difficult to determine the physiological significance of
this effect, as it is not clear whether prolonged fasting for
one month (similar to chronic dietary interventions) can
affect the coagulation factors without changing body
weight, plasma lipids and certain biochemical factors, or

380

Annals of Saudi Medicine, Vol 20, Nos 5-6, 2000

whether there are other parameters affecting the

coagulation and hematological systems response to the
fasting. We are unable to provide a definitive explanation,
as similar studies of peoples dietary habits during
Ramadan have not been done. Regarding the relationship
between Apo A1 and PT or PTT (Table 4), the significant
positive association did not exist during Ramadan,
furthermore, plasma lipid concentration (TG, HDL-C, TotC/HDL-C) had no effect on PTT during that month. This
was in contrast to other studies that showed a reduction of
plasma levels following interventions designed to reduce
hyperlipidemia.35
These analyses highlight the need to consider these
changes in biochemical or coagulation factor values when
physicians investigate patients during the month of
Ramadan. It is also important to keep the mentioned
associations in mind while investigating abnormalities of
these coagulation or biochemical factors.
Acknowledgements
The authors wish to acknowledge the valuable
contributions of the manager of Isfahan Cardiovascular
Research Center (ICVRC), Mr. M. Rafiei, and other staff
of ICVRC, including Miss Zarfeshani and Mr. Rezvani,
for their valuable secretarial assistance. Our appreciation
also goes to Mrs. F. Tafazoli, Mr. Hydarpoor and all
personnel of Feiz Hospital.
This research project was approved and supported by
the Isfahan Cardiovascular Research Center, the Deputy of
Research of Isfahan University of Medical Sciences, and
the Division of Cardiology of UCLA School of Medicine,
Los Angeles, U.S.A. The Lp(a) kits were donated by Dr.
Mohammad Navab, Professor and Co-Project Leader,
Division of Cardiology of UCLA School of Medicine, Los
Angeles, U.S.A.
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