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Interventions and public health nutrition

The effects of Ramadan fasting on endothelial function in patients with cardiovascular diseases



Endothelial dysfunction, which can be manifested by loss of nitric oxide bioavailability, is an increasingly recognized cause of cardiovascular diseases. Previous studies showed that diets affect endothelial function and modify cardiovascular risks. This study aimed to assess the effects of Ramadan fasting, as a diet intervention, on endothelial function.


The study population consisted of 21 male patients (mean age: 52±9 years) with cardiovascular risks (coronary artery disease, cerebrovascular or peripheral arterial diseases). The biochemical variables in serum of patients were measured 2 days before and after Ramadan fasting. The levels of asymmetric dimethylarginine (ADMA) and vascular endothelial growth factor (VEGF) were evaluated using the enzyme-linked immunosorbent assay. Nitric oxide (NO) and Malondialdehyde (MDA) levels were measured by the Griess and thiobarbituric acid reaction substances assay, respectively.


NO levels in patients after Ramadan fasting were significantly higher compared with the baseline value (85.1±11.54 vs 75.8±10.7 μmol/l) (P<0.05). Post-Ramadan levels of ADMA decreased significantly in comparison with pre-Ramadan levels (802.6±60.9 vs 837.6±51.0 nmol/l) (P<0.05). In addition, the levels of VEGF and MDA changed during Ramadan fasting, but these changes were not statistically significant (228.1±27.1 vs 222.7±22.9 pg/ml and 3.2±0.7 vs 3.6±1.1 μmol/l, respectively).


Ramadan fasting may have beneficial effects on endothelial function and can modulate cardiovascular risks. Further studies are needed to confirm the clinical significance of Ramadan fasting on cardiovascular health.

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  1. Leiper J, Molla A . Effects on health of fluid restriction during fasting in Ramadan. Eur J Clin Nutr 2003; 57: S30–S38.

    Article  Google Scholar 

  2. Al Suwaidi J, Bener A, Hajar H, Numan M . Does hospitalization for congestive heart failure occur more frequently in Ramadan: a population-based study (1991–2001). Int J Cardiol 2004; 96: 217–221.

    Article  CAS  Google Scholar 

  3. Sarraf-Zadegan N, Atashi M, Naderi GA, Baghai AM, Asgary S, Fatehifar MR et al. The effect of fasting in Ramadan on the values and interrelations between biochemical, coagulation and hematological factors. Ann Saudi Med 2000; 20: 377–381.

    Article  CAS  Google Scholar 

  4. Brown AA, Hu FB . Dietary modulation of endothelial function: implications for cardiovascular disease. Am J Clin Nutr 2001; 73: 673–686.

    Article  CAS  Google Scholar 

  5. De Caterina R . Endothelial dysfunctions: common denominators in vascular disease. Curr Opin Lipidol 2000; 11: 9–23.

    Article  CAS  Google Scholar 

  6. Heitzer T, Schlinzig T, Krohn K, Meinertz T, Münzel T . Endothelial dysfunction, oxidative stress, and risk of cardiovascular events in patients with coronary artery disease. Circulation 2001; 104: 2673–2678.

    Article  CAS  Google Scholar 

  7. Gimbrone MA Jr . Vascular endothelium: an integrator of pathophysiologic stimuli in atherosclerosis. Am J Cardiol 1995; 75: 67B–70B.

    Article  CAS  Google Scholar 

  8. Lerman A, Burnett J Jr . Intact and altered endothelium in regulation of vasomotion. Circulation 1992; 86: III12–III19.

    Article  CAS  Google Scholar 

  9. Cai H, Harrison DG . Endothelial dysfunction in cardiovascular diseases: the role of oxidant stress. Circ Res 2000; 87: 840–844.

    Article  CAS  Google Scholar 

  10. Böger RH . Asymmetric dimethylarginine (ADMA): a novel risk marker in cardiovascular medicine and beyond. Ann Med 2006; 38: 126–136.

    Article  Google Scholar 

  11. Sibal L, Agarwal SC, Home PD, Boger RH . The role of asymmetric dimethylarginine (ADMA) in endothelial dysfunction and cardiovascular disease. Curr Cardiol Rev 2010; 6: 82.

    Article  CAS  Google Scholar 

  12. Miyazaki H, Matsuoka H, Cooke JP, Usui M, Ueda S, Okuda S et al. Endogenous nitric oxide synthase inhibitor a novel marker of atherosclerosis. Circulation 1999; 99: 1141–1146.

    Article  CAS  Google Scholar 

  13. Fukumura D, Gohongi T, Kadambi A, Izumi Y, Ang J, Yun C-O et al. Predominant role of endothelial nitric oxide synthase in vascular endothelial growth factor-induced angiogenesis and vascular permeability. Proc Natl Acad Sci USA 2001; 98: 2604–2609.

    Article  CAS  Google Scholar 

  14. Hood JD, Meininger CJ, Ziche M, Granger HJ . VEGF upregulates ecNOS message, protein, and NO production in human endothelial cells. Am J Physiol Heart Circ Physiol 1998; 274: H1054–H1058.

    Article  CAS  Google Scholar 

  15. Murohara T, Horowitz JR, Silver M, Tsurumi Y, Chen D, Sullivan A et al. Vascular endothelial growth factor/vascular permeability factor enhances vascular permeability via nitric oxide and prostacyclin. Circulation 1998; 97: 99–107.

    Article  CAS  Google Scholar 

  16. Kadiiska M, Gladen B, Baird D, Germolec D, Graham L, Parker C et al. Biomarkers of Oxidative Stress Study II: Are oxidation products of lipids, proteins, and DNA markers of CCl4 poisoning? Free Radic Biol Med 2005; 38: 698–710.

    Article  CAS  Google Scholar 

  17. Badalzadeh R, Mohammadi M, Najafi M, Ahmadiasl N, Farajnia S, Ebrahimi H . The additive effects of ischemic postconditioning and cyclosporine-A on nitric oxide activity and functions of diabetic myocardium injured by ischemia/reperfusion. J Cardiovasc Pharmacol Ther 2012; 17: 181–189.

    Article  CAS  Google Scholar 

  18. Nezami N, Ghorbanihaghjo A, Rashtchizadeh N, Argani H, Tafrishinejad A, Ghorashi S et al. Atherogenic changes of low-density lipoprotein susceptibility to oxidation, and antioxidant enzymes in pulmonary tuberculosis. Atherosclerosis 2011; 217: 268–273.

    Article  CAS  Google Scholar 

  19. AW N, MI O, MR A . The Influence Of Ramadan Fasting On Cardiovascular Risk Factors. J Endocrinol Metab 2010; 1: 1.

    Google Scholar 

  20. Nematy M, Alinezhad-Namaghi M, Rashed MM, Mozhdehifard M, Sajjadi SS, Akhlaghi S et al. Effects of Ramadan fasting on cardiovascular risk factors: a prospective observational study. Nutr J 2012; 11: 69.

    Article  CAS  Google Scholar 

  21. Temizhan A, Dönderici Ö, Ouz D, Demirbas B . Is there any effect of Ramadan fasting on acute coronary heart disease events? Int J Cardiol 1999; 70: 149–153.

    Article  CAS  Google Scholar 

  22. Burazeri G, Goda A, Kark JD . Religious observance and acute coronary syndrome in predominantly Muslim Albania: a population-based case-control study in Tirana. Ann Epidemiol 2008; 18: 937–945.

    Article  Google Scholar 

  23. Mohler ER, Sibley AA, Stein R, Davila‐Roman V, Wyatt H, Badellino K et al. Endothelial function and weight loss: Comparison of low‐carbohydrate and low‐fat diets. Obesity 2013; 21: 504–509.

    Article  CAS  Google Scholar 

  24. Vanhoutte PM . Endothelial dysfunction: the first step toward coronary arteriosclerosis. Circ J 2009; 73: 595–601.

    Article  CAS  Google Scholar 

  25. Förstermann U . Nitric oxide and oxidative stress in vascular disease. Pflugers Arch 2010; 459: 923–939.

    Article  Google Scholar 

  26. Hagopian K, Harper M-E, Ram JJ, Humble SJ, Weindruch R, Ramsey JJ . Long-term calorie restriction reduces proton leak and hydrogen peroxide production in liver mitochondria. Am J Physiol Endocrinol Metab 2005; 288: E674–E684.

    Article  CAS  Google Scholar 

  27. Bevilacqua L, Ramsey JJ, Hagopian K, Weindruch R, Harper M-E . Effects of short-and medium-term calorie restriction on muscle mitochondrial proton leak and reactive oxygen species production. Am J Physiol Endocrinol Metab 2004; 286: E852–E861.

    Article  CAS  Google Scholar 

  28. Bevilacqua L, Ramsey JJ, Hagopian K, Weindruch R, Harper M-E . Long-term caloric restriction increases UCP3 content but decreases proton leak and reactive oxygen species production in rat skeletal muscle mitochondria. Am J Physiol Endocrinol Metab 2005; 289: E429–E438.

    Article  CAS  Google Scholar 

  29. Bastani A, Azadmanesh F, Ghorishi SM, Abdoljabary M, Bahrami Z, Heidari MH . Assessment of Malondialdehyde, 8-iso prostaglandin F2α, 8-hydroxy-2'-deoxyguanosine Factors and Protein Carbonyl Groups as Markers of Oxidative Stress in the Fasting Individuals in Tehran. J Appl Environ Biol Sci 2013; 3: 37–41.

    Google Scholar 

  30. Schulz E, Jansen T, Wenzel P, Daiber A, Münzel T . Nitric oxide, tetrahydrobiopterin, oxidative stress, and endothelial dysfunction in hypertension. Antioxid Redox Signal 2008; 10: 1115–1126.

    Article  CAS  Google Scholar 

  31. Smith CL, Birdsey GM, Anthony S, Arrigoni FI, Leiper JM, Vallance P . Dimethylarginine dimethylaminohydrolase activity modulates ADMA levels, VEGF expression, and cell phenotype. Biochem Biophys Res Commun 2003; 308: 984–989.

    Article  CAS  Google Scholar 

  32. Päivä H, Lehtimäki T, Laakso J, Ruokonen I, Tervonen R, Metso S et al. Dietary composition as a determinant of plasma asymmetric dimethylarginine in subjects with mild hypercholesterolemia. Metabolism 2004; 53: 1072–1075.

    Article  Google Scholar 

  33. Liu VW, Huang PL . Cardiovascular roles of nitric oxide: A review of insights from nitric oxide synthase gene disrupted mice. Cardiovasc Res 2008; 77: 19–29.

    CAS  PubMed  PubMed Central  Google Scholar 

  34. Mügge A, Hanefeld C, Böger RH . Plasma concentration of asymmetric dimethylarginine and the risk of coronary heart disease: rationale and design of the multicenter CARDIAC study. Atheroscler Suppl 2003; 4: 29–32.

    Article  Google Scholar 

  35. Dulak J, Józkowicz A, Dembinska-Kiec A, Guevara I, Zdzienicka A, Zmudzinska-Grochot D et al. Nitric oxide induces the synthesis of vascular endothelial growth factor by rat vascular smooth muscle cells. Arterioscler Thromb Vasc Biol 2000; 20: 659–666.

    Article  CAS  Google Scholar 

  36. Soydinç S, Çelik A, Demiryürek S, Davutoğlu V, Tarakçıoğlu M, Aksoy M . The relationship between oxidative stress, nitric oxide, and coronary artery disease. Eur J Gen Med 2007; 4: 62–66.

    Article  Google Scholar 

  37. Tanaga K, Bujo H, Inoue M, Mikami K, Kotani K, Takahashi K et al. Increased circulating malondialdehyde-modified LDL levels in patients with coronary artery diseases and their association with peak sizes of LDL particles. Arterioscler Thromb Vasc Biol 2002; 22: 662–666.

    Article  CAS  Google Scholar 

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We greatly appreciate Dr Amir Ghorbani-Haghjo and Dr Ali Mota for reviewing and critically reading the manuscript. We thank the Students’ Research Committee, Tabriz University of Medical Sciences for financial support.

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Correspondence to B Yousefi.

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Yousefi, B., Faghfoori, Z., Samadi, N. et al. The effects of Ramadan fasting on endothelial function in patients with cardiovascular diseases. Eur J Clin Nutr 68, 835–839 (2014).

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