Response to: letter to the editor - Islamic fasting: cardiovascular disease perspective

We would like to thank you for the opportunity to respond to Dr Castillo and Dr Salgado-Canales’ letter [1]. We would also like to appreciate the interest of Dr Castillo and Dr Salgado-Canales in our article detailing the cardiovascular disease perspective of Islamic fasting and taking the time to give their knowledgeable comments [2]. Our primary goal was to provide general guidelines for ‘riskfree’ fasting for cardiovascular disease (CVD) patients as there is minimum existing literature on these recommendations. The author raises an important concern specifically regarding the nutritional aspect of the recommendation that the beneficial impact of Ramadan fasting (RF) on lipid profile can not be generalized. We agree that the studies show a variable result therefore, we added that these can be attributed to the use of different methods of examination, examination of heterogeneous groups and individuals with different genetic backgrounds, different quantities/ quality of fats and carbohydrates consumed during night hours, different Ramadan diurnal fasting (RDIF) lengths, and different lifestyles and dietary patterns [3]. We also pointed out that energy, macro-, and micronutrient intakes before and after RDIF was not reported in most of these studies. We acknowledge the importance of consideration of the baseline parameters and the type and quality of food intake during the fast. Our healthcare professional (HCP) advice in the pre-Ramadan checklist included adequate fluid intake/balanced diet, smoking cessation trials, termination of fast if unwell, and recording experiences and feedback. We acknowledge the authors’ concern about adding specific nutritional recommendations for patients. Nutrition can play a huge role in the betterment or worsening of the lipid profile. Giovanni De Pergola et al. conducted a study on the Effects of a Low Carb Diet and Whey Proteins on Anthropometric, Hematochemical, and Cardiovascular Parameters in Subjects with Obesity which revealed low carbohydrate diet, enriched with whey proteins, maybe a good way to increase cardiac health and shows improvement of metabolic parameters as well [4]. Haiyan Meng et al. carried out a metaanalysis which resulted that relative to a non-diet control, intermittent fasting and energy-restricted diet is effective for the improvement of circulating total cholesterol, low-density lipoprotein cholesterol, and triacylglycerides concentrations [4]. Thus, we conclude the emphasis on taking a balanced diet (low carbs) and high fluid intake are no doubt mandatory, especially in hypertensive patients and there’s no harm in adding a Ramadan meal plan according to the patient’s needs and choices to the pre-Ramadan checklist. Ultimately, we agree with the authors that published data on Ramadan fasting are weak and observational, continued studies on CVD patients and RF will provide a clear picture of its effect on lipid parameters. Further studies are needed to explore gaps in knowledge around RF, nutritional plans, and effects on lipid profiles specifically designed for CVD patients to help refine current recommendations.