Nutrition, Metabolism & Cardiovascular Diseases (2013) 23, 1050e1057

Available online at www.sciencedirect.com

journal homepage: www.elsevier.com/locate/nmcd

Randomized cross-over trial of short-term

water-only fasting: Metabolic and
cardiovascular consequences
a,c,1,
B.D. Horne a,b,*,1, J.B. Muhlestein a,c,1, D.L. Lappe
H.T. May a,1, J.F. Carlquist a,c,1, O. Galenko a,1,
K.D. Brunisholz a,1, J.L. Anderson a,c,1
a

Intermountain Heart Institute, Intermountain Medical Center, Salt Lake City, UT, USA
Genetic Epidemiology Division, Department of Medicine, University of Utah, Salt Lake City,
UT, USA
c
Cardiology Division, Department of Medicine, University of Utah, Salt Lake City, UT, USA
b

Received 29 April 2012; received in revised form 27 September 2012; accepted 30 September 2012
Available online 7 December 2012

KEYWORDS
Fasting;
Erythrocyte;
Hemoglobin;
Human growth
hormone;
Energy restriction;
Caloric restriction;
FGF-21

Abstract Background and aims: Routine, periodic fasting is associated with a lower prevalence of coronary artery disease (CAD). Animal studies show that fasting may increase longevity
and alter biological parameters related to longevity. We evaluated whether fasting initiates
acute changes in biomarker expression in humans that may impact short- and long-term health.
Methods and results: Apparently-healthy volunteers (N Z 30) without a recent history of fasting
were enrolled in a randomized cross-over trial. A one-day water-only fast was the intervention
and changes in biomarkers were the study endpoints. Bonferroni correction required
p
0.00167 for significance (p < 0.05 was a trend that was only suggestively significant). The
one-day fasting intervention acutely increased human growth hormone (p Z 1.1  104), hemoglobin (p Z 4.8  107), red blood cell count (p Z 2.5  106), hematocrit (p Z 3.0  106), total
cholesterol (p Z 5.8  10 5 ), and high-density lipoprotein cholesterol (p Z 0.0015), and
decreased triglycerides (p Z 1.3  10 4 ), bicarbonate (p Z 3.9  10 4 ), and weight
(p Z 1.0  107), compared to a day of usual eating. For those randomized to fast the first day
(n Z 16), most factors including human growth hormone and cholesterol returned to baseline
after the full 48 h, with the exception of weight (p Z 2.5  104) and (suggestively significant)
triglycerides (p Z 0.028).
Conclusion: Fasting induced acute changes in biomarkers of metabolic, cardiovascular, and
general health. The long-term consequences of these short-term changes are unknown but

* Corresponding author. Intermountain Heart Institute, 5121 S. Cottonwood St., Salt Lake City, UT 84107, USA. Tel.: 1 801 507 4708; fax:
1 801 507 4792.
E-mail address: benjamin.horne@imail.org (B.D. Horne).
1
For the Intermountain Heart Collaborative Study Group.
0939-4753/$ - see front matter 2012 Elsevier B.V. All rights reserved.
http://dx.doi.org/10.1016/j.numecd.2012.09.007

Trial of short-term water-only fasting

1051

repeated episodes of periodic short-term fasting should be evaluated as a preventive treatment

with the potential to reduce metabolic disease risk.
Clinical trial registration (ClinicalTrials.gov): NCT01059760 (Expression of Longevity Genes in
Response to Extended Fasting [The Fasting and Expression of Longevity Genes during Food abstinence {FEELGOOD} Trial]).
2012 Elsevier B.V. All rights reserved.

Introduction
Routine, periodic fasting was previously associated with
a lower prevalence of coronary artery disease (CAD) [1].
That potential fasting benefit was hypothesized by logical
deduction based on multiple lines of evidence: 1) lower
cardiovascular mortality among Utahns and specifically
members of the Church of Jesus Christ of Latter-day Saints
(LDS, or Mormons) [2,3], 2) lower CAD risk among
Utahnsdindependent of tobacco use [1], and 3) a review of
shared behaviors of the LDS population [1]. That study
utilized no a priori biological hypothesis and a chance
finding could not be ruled out, but the finding was subsequently replicated in an independent population [4]. Those
epidemiologic studies provided no mechanistic explanation, but an association of fasting with lower risk of diabetes was observed [1,4].
Parallel research in animal models provides some potential insights that independently suggest a health benefit from
fasting, perhaps via the glucose metabolism pathway [5,6].
Some evidence indicates that a human genetic locus related
to those findings in animals is associated with glucose
concentration [7]. While those data hint at the hypothesis of
a metabolic effect, whether short-term fasting causes
persistent changes that benefit human health is unknown.
This study evaluated whether a short-term fasting
intervention acutely alters biochemical and physiological
parameters related to long-term risk. The objective was to
test whether 1 day of water-only fasting changes blood
levels of biomarkers of metabolic, cardiovascular, and
general health among apparently-healthy individuals.

Methods
The FEELGOOD trial was a two-day clinical cross-over trial
of apparently-healthy individuals that used a randomized
Latin square design. Participants acted as their own control
and, thus, intervention and control were matched for
participant factors such as age, sex, and body mass index
(BMI). Participants were included if they had not fasted
>12 h per episode for >1 year prior to enrollment, not
routinely participated in caloric restriction (i.e., deliberate
limitation to <80% of FDA recommended caloric intake) for
>2 years, and not deliberately skipped meals as a routine
dietary practice.

Study population
Individuals aged 18e70 years of either gender and any
ethnicity were eligible for enrollment. Individuals with
previous myocardial infarction, peripheral vascular disease,
or stroke, and those with immunodeficiency diseases were

excluded. Volunteers were excluded due to insulin use,

smoking, active cancer treatment, current treatment with
immunosuppressive medications, or solid organ transplantation within 1 year. An initial exclusion based on BMI
criteria was eliminated to increase enrollment.
Participants were randomized to either 28  4 h of
water-only fasting followed by 28  4 h fed or to 28  4 h
fed followed by 28  4 h of fasting. For practical purposes,
study follow-up visits were scheduled for 24 h after the
preceding visit, with 24 h being the minimum length of time
between visits. Laboratory samples were drawn and clinical
exam measurements made at baseline and at the one-day
and two-day time points.

Study endpoints
Thirty-six primary endpoints were designated, including
insulin, glucose, creatinine, sodium, potassium, calcium,
chloride, bicarbonate, blood urea nitrogen (BUN), homeostasis model assessment-insulin resistance (HOMA-IR, using
the HOMA2 algorithm) [8], human growth hormone (HGH),
white blood cell count (WBC), red blood cell count (RBC),
hemoglobin, hematocrit, platelet count, red cell distribution
width (RDW), mean corpuscular hemoglobin (MCH), mean
corpuscular hemoglobin concentration (MCHC), mean
platelet volume (MPV), mean corpuscular volume (MCV), total
cholesterol, LDL-C, high-density lipoprotein cholesterol
(HDL-C), triglycerides, total cholesterol to HDL-C (TC:HDL)
ratio, high-sensitivity C-reactive protein (hsCRP), sitting and
supine SBP and DBP, weight, waist circumference, adiponectin (ratio of high molecular weight to total), glycogen-like
protein-1 (GLP-1), and fibroblast growth factor-21 (FGF-21).
The original design designated the primary endpoint as
changes in expression of the FOXA1, FOXA2, and FOXA3
genes (www.clinicaltrials.gov: NCT01059760), which
hypothesis was based on prior animal evidence of a fasting
effect [5,6]. Patient mRNA samples were collected by
venipuncture in Paxgene Blood RNA tubes and total plasma
mRNA was isolated using Paxgene Blood RNA kit (PreAnalytiX) by manufacturer recommendations with oncolumn treatment of RNaseeFree DNase 1 (Qiagen). Foxa
transcripts were quantified with TaqMan gene expression
assays (Applied BioSystems, Inc) and GAPDH was used as an
endogenous control for normalization. Due to the number
of samples with mRNA transcripts beyond the detection
limit of the assay, gene expression of the three FOXA genes
were not analyzed statistically.

Statistical considerations
Change scores for each parameter were compared between
fasting and fed days by paired T-test. Linear regression was

1052

B.D. Horne et al.

used to evaluate whether age, sex, or BMI predicted the

difference between the fasting and fed change score for
each variable that was significant in the primary paired Ttest analysis. Statistical significance using the Bonferroni
correction was utilized, with correction for 30 independent
tests of hypothesis and a p-value of p
0.00167 (0.05/30)
required to declare significance. Only 30 of the 36 comparisons were considered independent because chloride, BUN,
MCH, RBC, and hematocrit were found previously to provide
redundant information [9], and because the sitting and
supine SBP herein were not independent. P < 0.05 was
designated as a trend that was suggestive of statistical
significance, but that did not achieve significance.

Results
Among N Z 30 participants, age averaged 43.6  13.5 years
(range: 19.5e64.4 years) and 66.7% were female. Baseline
BMI averaged 27.8  1.3 kg/m2 and mean hemoglobin A1C
was 5.4%  0.3% (range: 4.7%e5.9%). Only hsCRP differed
between randomization groups (Table 1). Mean age was
36.1  14.9 years for males and 48.6  11.1 years for
females (p Z 0.022), with mean BMIs of 29.6  7.5 kg/m2
and 27.0  6.1 kg/m2 (p Z 0.34). Adverse trial events were
2 (7%) mild headaches and 1 (3%) migraine.
For metabolic outcomes (Table 2), the one-day fast
significantly increased HGH (p Z 1.1  104). Nonsignificant (p > 0.00167) changes were observed (Table 2)
in glucose (p Z 0.0069), insulin (p Z 0.022), HOMA-IR
(p Z 0.013), and GLP-1 (p Z 0.041). No changes were
found in adiponectin (p Z 0.21) or FGF-21 (p Z 0.23).
General health endpoints increased by fasting were
hemoglobin (4.8  107), RBC (2.5  106), and hematocrit
(3.0  106) (Table 2), while bicarbonate was decreased
(3.9  104). Sodium demonstrated a strong trend downward (p Z 0.0018). No changes were found for platelet
count, potassium, or various other parameters (Table 2).
Cardiac risk factor outcomes are shown in Table 2.
Weight (1.0  107) and triglycerides (1.3  104) were

Table 1

decreased by fasting, while total cholesterol (5.8  105)

and HDL-C (p Z 0.0015) were increased. A suggestively
significant increase was recorded for LDL-C (p Z 0.0051).
Figure 1AeC highlights several analytes impacted by
fasting.
Linear regression evaluating the difference between
changes while fasting vs. fed showed that HGH changed
more among participants who were younger (p Z 0.019)
and had lower BMI (p Z 0.032), while changes in bicarbonate were greater among females (p Z 0.034) and those
with lower BMI (p < 0.001). No other such interactions were
observed for other analytes. Paired T-tests within age tertiles (age ranges: 19.5e31.3, 31.4e52.7, 52.8e64.4 years)
revealed HGH changes of 2.0  2.2 and 1.7  2.1 ng/mL
for fasting and fed, respectively, in tertile 1 (p Z 0.040),
1.1  1.0 vs. 0.8  1.0 ng/mL for tertile 2 (p Z 0.016),
and 0.2  1.3 vs. 0.9  1.5 ng/mL for tertile 3 (p Z 0.08).
Analyses in BMI tertiles (BMI ranges: 17.7e24.0, 24.1e29.8,
and 29.9e41.3 kg/m2) showed that HGH changes on fasting
vs. fed days were, respectively, 2.1  3.8 vs.
1.5  2.0 ng/mL for tertile one (p Z 0.032), 1.6  1.8 vs.
2.0  1.9 ng/mL for tertile two (p Z 0.010), and 0.4  0.6
vs. 0.3  0.5 ng/mL for tertile three (p Z 0.023).
For bicarbonate, the changes were similar (p Z 0.58) in
the third BMI tertile for fasting vs. fed (0.3  1.1,
0.7  1.9 mmol/L), but were larger for the second tertile
(fasting vs. fed: 1.6  2.1, 1.0  1.3 mmol/L, p Z 0.038)
and first tertile (fasting vs. fed: 2.4  1.3,
2.2  2.2 mmol/L, p < 0.001). Bicarbonate changes among
females were 1.7  1.7 vs. 1.5  2.0 mmol/L for fasting
vs. fed (p < 0.001) and 0.9  1.4 vs. 0.3  2.2 mmol/L
for males (p Z 0.50). Stratification by the age, sex, and BMI
factors above are illustrated in Fig. 1D, E.
The relative magnitude of biomarker levels, measured as
the ratio of fasting to fed values (not the ratio of the
change scores), was higher for HGH among males compared
to females (13.6-fold vs. 4.7-fold, p Z 0.011). The greater
ratio among males was ascribed to a lower average baseline
and fed HGH than females, with fed values of 0.17  0.35
and 0.40  0.52 ng/mL for males and females, respectively,

Characteristics of participants enrolled in the FEELGOOD trial.

Characteristic

Fasting day first (n Z 16)a

Fed day first (n Z 14)a

p-value

Age (years)
Sex (female)
BMI (kg/m2)
Waist circumference (cm)
Glucose (mg/dL)
Hemoglobin A1C
SBP, supine (mmHg)
DBP, supine (mmHg)
Total cholesterol (mg/dL)
LDL-C (mg/dL)
HDL-C (mg/dL)
Triglycerides (mg/dL)
hsCRP (mg/L)b

43.3  13.6
68.8%
28.4  7.1
87.7  17.4
81.4  15.1
5.5%  0.3%
115  14
68.2  8.6
192  27
106  31
54.4  12.1
132  46
2.80 (1.62)

44.0  14.0
64.3%
27.3  6.1
86.1  16.2
83.4  19.7
5.3%  0.3%
114  9
68.8  7.0
190  34
103  27
56.3  19.7
156  87
0.75 (0.71)

0.91
0.80
0.69
0.82
0.76
0.19
0.88
0.86
0.92
0.78
0.75
0.35
0.008

a
Randomization was 1:1 by Latin square to either 1 day of fasting followed by a day of eating (fasting day first: n Z 16) or to a day of
eating followed by the fasting day (fed day first: n Z 14).
b
Values of hsCRP are median (standard error).

Trial of short-term water-only fasting

Table 2

1053

Changes in participant parameters when fasting and fed (N Z 30).

Characteristic

Baseline value

Change while
fasting

Change when
fed

p-value for
change scores

HGH (ng/mL)
Glucose (mg/dL)
Insulin (mU/L)
HOMA-IRa
GLP-1 (ng/mL)
Adiponectinb
FGF-21 (pg/mL)
WBC (/mL)
Hemoglobin (g/dL)
RBC (106/mL)
Hematocrit (%)
Platelet count (103/mL)
MCV (fL)
MCH (pg)
MCHC (g/dL)
RDW (%)
MPV (fL)
Bicarbonate (mmol/L)
Sodium (mmol/L)
Chloride (mmol/L)
BUN (mg/dL)
Calcium (mg/dL)
Potassium (mmol/L)
Creatinine (mg/dL)
Total cholesterol (mg/dL)
LDL-C (mg/dL)
HDL-C (mg/dL)
Triglycerides (mg/dL)
TC/HDL ratio
Weight (kg)
Waist circumference (cm)
SBP, supine (mmHg)c
DBP, supine (mmHg)c
hsCRP (mg/L)d

0.32  0.47
83.3  15.8
23.6  17.8
0.66  0.51
1.77  0.79
0.34  0.17
190.3  261.4
6.0  1.4
14.3  1.3
4.7  0.4
41.6  3.6
253.5  58.2
89.11  3.56
30.66  1.48
34.4  0.5
13.60  0.82
8.17  0.83
27.0  2.5
139.1  2.0
103.7  2.7
16.0  3.7
9.4  0.3
4.29  0.28
0.848  0.118
190.7  30.7
103.8  33.8
55.9  14.3
134.2  77.0
3.63  1.15
81.3  25.0
86.7  16.7
114.0  13.6
67.2  8.8
1.35 (0.96)

1.54  2.63
8.0  15.4
19.0  29.3
0.35  0.53
0.27  0.51
0.02  0.25
41.7  128.9
0.32  1.31
0.46  0.37
0.15  0.13
1.3  1.3
2.8  16.3
0.12  0.68
0.01  0.33
0.02  0.49
0.04  0.32
0.02  0.41
1.4  1.7
1.4  2.1
1.3  2.0
1.2  3.9
0.18  0.34
0.02  0.30
0.005  0.09
9.5  10.6
23.1  35.1
3.7  5.3
52.4  55.5
3.3  17.7
1.5  0.9
0.57  1.4
3.1  8.4
1.7  7.4
0.00 (0.44)

1.14
5.9
1.6
0.02
0.07
0.07
9.5
0.12
0.39
0.11
1.1
0.9
0.18
0.07
0.01
0.03
0.03
0.9
0.7
0.9
1.8
0.12
0.02
0.002
4.8
10.3
1.0
11.2
0.0
0.5
0.54
1.0
1.2
0.10

1.1  104*
0.0069
0.022
0.017
0.041
0.21
0.23
0.32
4.8  107*
2.5  106*
3.0  106*
0.72
0.79
0.60
0.84
0.95
0.88
3.9  104*
0.0018
0.0037
0.0065
0.0087
0.67
0.89
5.8  105*
0.0051
0.0015*
1.3  104*
0.32
1.0  107*
0.13
0.19
0.32
0.60

 1.66
 16.6
 16.2
 0.30
 0.51
 0.25
 108.8
 1.48
 0.52
 0.17
 1.5
 13.8
 0.73
 0.40
 0.52
 0.37
 0.26
 2.2
 2.0
 2.3
 2.6
 0.33
 0.32
 0.06
 11.0
 28.2
 3.6
 38.1
 0.2
 0.9
 3.0
 9.6
 8.9
(0.24)

*Correction for multiple comparisons required p
0.00167 for significance (p < 0.05 is suggestively significant).
a
HOMA-IR used the HOMA2 model [8].
b
Adiponectin values are given for the ratio of high molecular weight adiponectin to the total adiponectin.
c
Sitting SBP and DBP were similar (data not shown).
d
Values of hsCRP are median (standard error).

while the average after fasting was slightly higher for males
(2.23  2.61 vs. females: 1.98  2.41 ng/mL).
The fasting:fed ratios were 1.05 and 1.03 for hemoglobin
among females and males (p Z 0.22), respectively (results
for RBC and hematocrit were similar), 0.93 and 0.98 for
bicarbonate (p Z 0.07), and 1.07 and 1.03 for total
cholesterol (p Z 0.025, HDL-C results were similar). The
only difference in the ratios based on BMI was for bicarbonate (0.90, 0.95 and 0.997 for tertiles 1, 2, and 3,
respectively, p Z 0.009) and no differences were seen
based on age.
Among the 16 individuals randomized to fasting on the
first study day, all factors except weight (p Z 2.5  104)
returned to baseline after the full 48 h of the study
(Table 3), although triglycerides had a trend (p Z 0.028)
toward not having returned to baseline. In contrast, RBC

(p Z 0.017) and hematocrit (p Z 0.0061) had suggestively

significant trends toward having decreased on the fed day
below baseline.

Discussion
Fasting (complete caloric desistance) and caloric restriction (partial limitation of calorie intake) are similar
methods of energy restriction that may influence human
health [10e12]. Differences may exist in the biological
source of their health benefits [5,6], consistent with the
knowledge that various cardiovascular pathways exist
through which dietary factors may act [13]. Previously, in
a population in which many patients routinely engage in
fasting over the life span for religious purposes (for 24 h

1054

B.D. Horne et al.

about once per month), repeated analyses showed that
periodic fasting was associated with lower risk of CAD and
diabetes [1,4]. A meta-analysis found that the adjusted
odds of diabetes was 43% lower for those who fast routinely
compared to non-fasters, and for CAD it was 42% lower
[1,4]. The question remained, though, whether fasting
exerts a biological effect, such as via a stress-response
mechanism [14,15], or simply identifies individuals with
better health or who follow a cluster of preventive
behaviors [16].
The present trial illuminates multiple biological
endpoints that, after comprehensive correction for
multiple statistical comparisons, were acutely changed by
1 day of water-only fasting. These biological endpoints
included measures of metabolic, cardiovascular, and
general health such as HGH, cholesterol, and erythrocyterelated factors. While it is expected that cessation of
caloric intake will alter some biological parameters, several
of the changed factors are linked to risk pathways and
should be further investigated in conjunction with fasting.
Observed increases in hemoglobin, RBC, and hematocrit
may be due to inhibited eryptosis or accelerated erythropoiesis. Conversely, hemoconcentration due to dehydration
or other loss of plasma volume is also a possible source.
Dehydration is not likely because it causes hypernatremia
[17,18], and this study documented a strong trend toward
lower sodium (hyponatremia) during fasting. Decreased
sodium is consistent with a phenomenon termed the natriuresis of fasting [19], which sodium loss could decrease
plasma volume; however, this would also increase platelet
count and no change in platelet count was observed [18].
Adequate hydration during fasting was taught to participants
to prevent adverse events such as dehydration-induced
stroke [20,21], to ensure sufficient target vein size for
peripheral blood draws, and to ease hunger pangs. Further,
water intake was reported consistently by the participants in
post-fasting interviews. Based on these evidences, we
conclude that participants were adequately hydrated and
the observed increases in the erythrocyte-related factors
are due to physiology other than hemoconcentration.
We are aware of no prior study reporting increased
hemoglobin, RBCs, or hematocrit in response to fasting.

Figure 1 Selected box and whisker plots (N Z 30) with

values at baseline, the end of the fasting day, and the end of
the fed day for: A) human growth hormone, B) red blood cell
count (similar to hemoglobin and hematocrit values), and C)
total cholesterol levels (similar to high-density lipoprotein and
low-density lipoprotein cholesterol). Comparison between
fasting levels and baseline and between fasting and fed had
p < 0.001 for graphs A, B, and C, but comparison between
baseline and fed were not (p > 0.05). Changes differed for: D)
human growth hormone by age and sex strata (males in third
age tertile had n Z 1) and E) bicarbonate by body mass index
and sex strata (females in third BMI tertile had n Z 3, with dots
indicating outlying values). (Boxes represent the 25th to 75th
percentile of the data, the solid line is the median, and the
ends of the whiskers are the most extreme values within 1.5
times the interquartile range below the 25th percentile and
above the 75th percentile.)

Trial of short-term water-only fasting

1055

Table 3 Among only those participants (n Z 16) who were randomized to fast the first day (and eat on the second day), an
evaluation of the normalization of factors that were significantly altered by fasting.
Characteristic

Baseline value
(hour 0)

HGH (ng/mL)
Hemoglobin (g/dL)
RBC (106/mL)
Hematocrit (%)
Bicarbonate (mmol/L)
Total cholesterol (mg/dL)
HDL-C (mg/dL)
Triglycerides (mg/dL)
Weight (kg)

0.73
14.2
4.65
41.6
27.3
192
54.4
132
82.5











1.43
1.2
0.32
3.4
1.5
27
12.1
46
26.8

Value after fasting

day (hour 24)
1.75
14.6
4.78
42.7
25.9
200
57.4
94
81.2











1.77a
1.1a
0.33a
3.2a
1.7a
32a
12.1a
33a
26.5a

Value after fed

day (hour 48)
0.37
14.1
4.58
40.9
27.4
189
55.3
106
81.7











0.60
1.3
0.35
3.5
2.5
28
11.6
38
26.7

p-value for baseline

vs. fed (hour 48)
0.36
0.13
0.017
0.0061
0.84
0.39
0.49
0.028
2.5  104*

*Correction for multiple comparisons required p
0.00167 for significance (p < 0.05 is suggestively significant).
a
The fasting value was changed compared to baseline (p < 0.05).

Interestingly, loss of plasma volume during natriuresis

would trigger angiotensin II production, which is implicated
in increasing erythropoietin [22] and, consequently, RBC
mass (a method of preserving sufficient plasma volume for
adequate circulation). As a side note, natriuresis of fasting
is worthy of further investigation for potential effects on
cardiovascular health since stimulating natriuresis to
decrease sodium is a goal of anti-hypertensive treatment
that lowers cardiovascular risk [22].
Because RBCs, hemoglobin, and hematocrit are
increased by medical treatment with exogenous erythropoietin, data on such therapy are salient. In animal models,
over-expression of and injection with erythropoietin
increase fat oxidation and decrease glucose levels, insulin,
hemoglobin A1C, adipose tissue mass, and weight [23,24].
In humans, treatment with recombinant erythropoietin is
associated with lower insulin resistance and insulin levels,
while patients on longer length of therapy have greater
improvements in glucose, insulin, and insulin resistance
than short-term erythropoietin treatment [25e27]. Further
investigation is required to determine whether fastinginduced increases in erythrocyte parameters alter adipocytes or insulin resistance.
Among other endpoints, increased total cholesterol was
not due to triglyceride changes since a precipitous triglyceride decrease was observed, but because of increases in
circulating HDL-C and LDL-C. Increased serum cholesterol
may arise from the extraction of lipids from endogenous
stores or a decreased lipoprotein uptake by the liver, or
both. Raised cholesterol due to fasting was previously reported in a study of ten individuals [28], and similar
cholesterol elevations were also reported among hibernating bears [29]. An increase in circulating lipid molecules
is consistent with the concept that erythrocyte concentrations are increased and adipocytes are oxidized during
fasting. Lipid levels may also have increased due to
extraction of lipid stores from other cholesterol-harboring
tissues (e.g., atheromatous lesions). These and other
proposals should be further investigated to determine
whether such changes translate into long-term reductions
in metabolic and cardiovascular risk.
In the present study, fasting elevated HGH by 1360%
among males and 470% in females during a 24 h period. Long

known to influence height in children, HGH is now known to

antagonize insulins effects and help regulate the metabolism among adults by causing acute insulin resistance and
stimulating lipolysis [30,31]. This may lead to a reduction in
abdominal fat that is the primary source of chronic insulin
resistance [31]. Among individuals with HGH-deficiency
syndromes, HGH treatment improves markers of metabolic risk [31]. Recombinant HGH was shown to reduce
adipose tissue and improve lean body mass [32], although
claims of longevity enhancement by HGH injection are not
supported [33]. HGH was shown previously to be increased
by fasting [34,35], but further research is needed to evaluate whether short-term increases in HGH modulate longterm metabolic and CAD risk. Interestingly, sleep and
physical activity are both known to acutely increase HGH
and are associated with lower CAD risk [36,37].
Of note, some data suggest that a specific type of fastingdalternate day fastingdmay not be beneficial. A six
month study of alternate day fasting among rats showed
increased myocardial fibrosis, reduced cardiac reserve, and
increased left atrial diameter [38]. Although left ventricular size and ejection fraction were unchanged, the
adverse effects related to diastolic dysfunction should not
be overlooked. It may be that excessive amounts of fasting
are deleterious, thus caution should be taken in research
and applied implementations of fasting.
This study is limited to measurements of short-term
changes in risk markers, thus its implications for longerterm outcomes across repeated fasting episodes requires
further investigation. The study was also limited because
many patient samples had undetectable mRNA transcript
levels, with FOXA2 mRNA detected in only 2 (2%) of the 90
samples (100% of the 30 patients had two or more undetectable values), FOXA1 mRNA was found in only 33
samples (37%) with at least one measurement undetectable
for 26 patients (87%), and FOXA3 mRNA was not measureable in 7 samples (8%) from 6 of the 30 patients (20%), thus
gene expression endpoints were not evaluable. Another
limitation of this study was that no measures of glycogenolysis or lipolysis were made, thus more in-depth data
regarding these processes and other factors such as
albumin and lactate should be studied in future
investigations.

1056

Conclusions
A clinical interventional trial by 1 day of water-only fasting
recorded acute improvements in biomarkers of metabolic
risk, including profound changes in measures of erythrocyte
concentration, cholesterol, and HGH. These short-term
changes were normalized to baseline levels within oneday after fasting, but the specific factors that changed
suggest the potential for long-term metabolic and cardiovascular benefits. Further evaluation is needed to determine whether those short-term changes produce persistent
health benefits. If so, fasting could potentially be used to
prevent diabetes and CAD among those in a pre-diabetic
state with intermediate fasting glucose (e.g., glucose
100e125 mg/dL) or with metabolic syndrome. The possibility that fasting is an intensive biologically-programmed
treatment that can produce long-term improvements in
health indicates that water-only fasting deserves long-term
prospective clinical evaluation [39].

Funding
This study was funded by a grant from the Intermountain
Research and Medical Foundation, Salt Lake City, UT. The
funding organization had no role in the design or conduct of
the study, the collection, management, analysis, or interpretation of the data, or the preparation, review, or
approval of the manuscript.

Conflicts of interest
The authors have nothing to disclose.

References
[1] Horne BD, May HT, Anderson JL, Kfoury AG, Bailey BM,
McClure BS, et al. Usefulness of routine periodic fasting to
lower risk of coronary artery disease among patients undergoing coronary angiography. Am J Cardiol 2008;102:814e9.
[2] Lyon JL, Wetzler HP, Gardner JW, Klauber MR, Williams RR.
Cardiovascular mortality in Mormons and non-Mormons in
Utah, 1969e1971. Am J Epidemiol 1978;108:357e66.
[3] Enstrom JE. Health practices and cancer mortality among
active California Mormons. J Natl Cancer Inst 1989;81:
1807e14.
[4] Horne BD, Muhlestein JB, May HT, Carlquist JF, Lappe
DL,
Bair TL, et al. Relation of routine, periodic fasting to risk of
diabetes mellitus and coronary artery disease among patients
undergoing coronary angiography. Am J Cardiol 2012;109:
1558e62.
[5] Zhang L, Rubins NE, Ahima RS, Greenbaum LE, Kaestner KH.
Foxa2 integrates the transcriptional response of the hepatocyte to fasting. Cell Metab 2005;2:141e8.
[6] Panowski SH, Wolff S, Aguilaniu H, Durieux J, Dillin A. PHA4/Foxa mediates diet-restriction-induced longevity of C. elegans. Nature 2007;447:550e6.
[7] Xing C, Cohen JC, Boerwinkle E. A weighted false discovery
rate control procedure reveals alleles at FOXA2 that influence
fasting glucose levels. Am J Hum Genet 2010;86:440e6.
[8] Wallace TM, Levy JC, Matthews DR. Use and abuse of HOMA
modeling. Diabetes Care 2004;27:1487e95.

B.D. Horne et al.

[9] Horne BD, May HT, Muhlestein JB, Ronnow BS, Lappe
DL,
Renlund DG, et al. Exceptional mortality prediction by risk
scores from common laboratory tests. Am J Med 2009;122:
550e8.
[10] Fontana L, Klein S. Aging, adiposity, and calorie restriction.
JAMA 2007;297:986e94.
[11] Hietaniemi M, Jokela M, Rantala M, Ukkola O, Vuoristto JT,
Ilves M, et al. The effect of a short-term hypocaloric diet on
liver gene expression and metabolic risk factors in obese
women. Nutr Metab Cardiovasc Dis 2009;19:177e83.
[12] Tapsell L, Batterham M, Huang XF, Tan SY, Teuss G,
Charlton K, et al. Short term effects of energy restriction and
dietary fat sub-type on weight loss and disease risk factors.
Nutr Metab Cardiovasc Dis 2010;20:317e25.
[13] Borriello A, Cucciolla V, Della Ragione F, Galletti P. Dietary
polyphenols: focus on resveratrol, a promising agent in the
prevention of cardiovascular diseases and control of glucose
homeostasis. Nutr Metab Cardiovasc Dis 2010;20:618e25.
[14] Raffaghello L, Lee C, Safdie FM, Wei M, Madia F, Bianchi G,
et al. Starvation-dependent differential stress resistance
protects normal but not cancer cells against high-dose
chemotherapy. Proc Natl Acad Sci U S A 2008;105:8215e20.
[15] Wan R, Camandola S, Mattson MP. Intermittent fasting and
dietary supplementation with 2-deoxy-D-glucose improve
functional and metabolic cardiovascular risk factors in rats.
FASEB J 2003;17:1133e4.
[16] Enstrom JE, Breslow L. Lifestyle and reduced mortality among
active California Mormons, 1980e2004. Prev Med 2008;46:
133e6.
[17] Singer GG, Brenner BM. Fluid and electrolyte disturbances. In:
Fauci AS, Braunwald E, Isselbacher KJ, Wilson JD, Martin JB,
Kasper DL, et al., editors. Harrisons principles of internal
medicine. New York: McGraw-Hill Companies, Inc.; 1998. p. 269.
[18] Singh R, Sirisinghe RG. Haematological and plasma electrolyte
changes after long distance running in high heat and humidity.
Singapore Med J 1999;40:84e7.
[19] Spark RF, Arky RA, Boulter PR, Saudek CD, OBrian JT. Renin,
aldosterone and glucagon in the natriuresis of fasting. N Engl J
Med 1975;292:1335e40.
[20] Yasaka M, Yamaguchi T, Oita J, Sawada T, Shichiri M, Omae T.
Clinical features of recurrent embolization in acute cardioembolic stroke. Stroke 1993;24:1681e5.
[21] Nadav L, Gur AY, Korczyn AD, Bornstein NM. Stroke in hospitalized patients: are there special risk factors? Cerebrovasc
Dis 2002;13:127e31.
[22] Gossmann J, Thurmann P, Bachmann T, Weller S, Kachel HG,
Schoeppe W, et al. Mechanism of angiotensin converting
enzyme inhibitor-related anemia in renal transplant recipients. Kidney Int 1996;50:973e8.
[23] Hojman P, Brolin C, Gissel H, Brandt C, Zerahn B, Pedersen BK,
et al. Erythropoietin over-expression protects against dietinduced obesity in mice through increased fat oxidation in
muscles. PLoS One 2009;4:e5894.
[24] Katz O, Stuible M, Golishevski N, Lifshitz L, Tremblay ML,
Gassmann M, et al. Erythropoietin treatment leads to reduced
blood glucose levels and body mass: insights from murine
models. J Endocrinol 2010;205:87e95.
[25] Tuzcu A, Bahceci M, Yilmaz E, Bahceci S, Tuzcu S. The
comparison of insulin sensitivity in non-diabetic hemodialysis
patients treated with and without recombinant human
erythropoietin. Horm Metab Res 2004;36:716e20.
[26] Rasic-Milutinovic Z, Perunicic-Pekovic G, Cavala A, Gluvic Z,
Bokan L, Stankovic S. The effect of recombinant human
erythropoietin treatment on insulin resistance and inflammatory markers in non-diabetic patients on maintenance
hemodialysis. Hippokratia 2008;12:157e61.
[27] Khedr E, El-Sharkawy M, Abdulwahab S, Eldin EN, Ali M,
Youssif A, et al. Effect of recombinant human erythropoietin

Trial of short-term water-only fasting

[28]

[29]

[30]

[31]

[32]

[33]

on insulin resistance in hemodialysis patients. Hemodial Int

2009;13:340e6.
Sa
vendahl L, Underwood LE. Fasting increases serum total
cholesterol, LDL cholesterol, and apolipoprotein B in healthy,
nonobese humans. J Nutr 1999;129:2005e8.
LeBlanc PJ, Obbard M, Battersby BJ, Felskie AK, Brown L,
Wright PA, et al. Correlations of plasma lipid metabolites with
hibernation and lactation in wild black bears Ursus americanus. J Comp Physiol B 2001;171:327e34.
Norrelund H, Nielsen S, Christiansen JS, Jorgensen JOL,
Moller N. Modulation of basal glucose metabolism and insulin
sensitivity by growth hormone and free fatty acids during
short-term fasting. Eur J Endocrinol 2004;150:779e87.
Norrelund H. The metabolic role of growth hormone in humans
with particular reference to fasting. Growth Horm IGF Res
2005;15:95e122.
Rudman D, Feller AG, Nagraj HS, Gergans GA, Lalitha PY,
Goldberg AF, et al. Effects of human growth hormone in men
over 60 years old. N Engl J Med 1990;323:1e6.
Liu H, Bravata DM, Olkin I, Nayak S, Roberts B, Garber AM,
et al. Systematic review: the safety and efficacy of growth

1057

[34]

[35]

[36]
[37]
[38]

[39]

hormone in the healthy elderly. Ann Intern Med 2007;146:

104e15.
Merimee TJ, Pulkkinen AJ, Burton CE. Diet-induced alterations of hGH secretion in man. J Clin Endocrinol Metab 1976;
42:931e7.
Ho KY, Veldhuis JD, Johnson ML, Furlanetto R, Evans WS,
Alberti KGMM, et al. Fasting enhances growth hormone
secretion and amplifies the complex rhythms of growth
hormone secretion in man. J Clin Invest 1988;81:968e75.
Godfrey RJ, Madgwick Z, Whyte GP. The exercise-induced growth
hormone response in athletes. Sports Med 2003;33:599e613.
VanderLaan WP. Changing concepts on the control of growth
hormone secretion in man. Calif Med 1971;115:38e46.
Ahmet I, Wan R, Mattson MP, Lakatta EG, Talan MI. Chronic
alternate-day fasting results in reduced diastolic compliance and
diminished systolic reserve in rats. J Card Fail 2010;16:843e53.
Anson RM, Guo Z, de Cabo R, Iyun T, Rios M, Hagepanos A,
et al. Intermittent fasting dissociates beneficial effects of
dietary restriction on glucose metabolism and neuronal
resistance to injury from calorie intake. Proc Natl Acad Sci U S
A 2003;100:6216e20.