Fasting completion rates during Ramadan are significantly influenced by the time elapsed since surgery and previous experience

Fasting completion rates during Ramadan are significantly influenced by the time elapsed since surgery, with patients who underwent laparoscopic sleeve gastrectomy (LSG) 12 months or more before Ramadan having the highest success rates, according to researchers from Benha University, Benha and Tanta University, Tanta, Egypt. In addition, prior fasting experiences positively impacted fasting completion rates.

The study authors stated that fasting during Ramadan presents unique challenges for post-bariatric surgery patients and the effects of fasting after LSG remain unclear, particularly regarding symptom prevalence and fasting success rates. This study evaluated the optimal timing for fasting after LSG and provided guidance for safely observing Ramadan.

This retrospective observational study analysed the experiences of 100 patients (aged 21 to 50 years, 56 females) who underwent LSG at varying durations before Ramadan (three, six, nine and 12+ months) in Egypt. The participants were surveyed regarding their fasting experiences during Ramadan, including completion rates, symptoms encountered and any medical interventions required.

The participants were divided into four groups based on the duration of surgery: (1) three months post-surgery: patients who underwent LSG within three months before Ramadan; (2) six months post-surgery: patients who underwent LSG within six months before Ramadan; (3) nine months post-surgery: patients who underwent LSG within nine months before Ramadan; and (4) 12+ months post-surgery: patients who underwent LSG 12 months or more before Ramadan.

Data were collected through a structured questionnaire administered to participants after Ramadan. The questionnaire captured the following information: (1) fasting completion: whether the participant completed the full month of Ramadan (yes or no) and whether they experienced any complications requiring hospital admission or intravenous fluids; (2) experienced symptoms: participants reported the occurrence of GERD, vomiting, dumping syndrome, dehydration, and other gastrointestinal symptoms during Ramadan; (3) nutritional status: the presence of calcium, vitamin D, and vitamin B deficiencies was assessed using subjective self-reported symptoms and medical records; (4) hydration practices: participants were asked about their fluid intake during non-fasting hours, with a focus on adherence to recommended hydration guidelines (minimum 1.5 litres per day); and (5) physical activity: participants reported whether they maintained physical activity during Ramadan and any adjustments made to exercise intensity or timing.

The primary outcome measure was the ability to complete Ramadan fasting without requiring hospital admission or intravenous fluid administration. Secondary outcomes included the prevalence of GERD, vomiting, dumping syndrome, and other gastrointestinal symptoms, as well as nutritional status and hydration practices.

Outcomes

The findings revealed that fasting completion rates were significantly influenced by the time elapsed since the surgery (Figure 1). These data suggest a significant association between the time elapsed post-surgery and fasting success. Patients who completed the fast had a longer median duration after surgery, typically ranging between ten and 20 months, with some extending beyond 24 months.

Figure 1: Completion of Ramadan fasting according to the duration since LSG. Data are presented as the number (N) and percentage (%) of patients who successfully completed fasting.

This trend indicates that a longer post-LSG recovery period may enhance patients’ ability to tolerate prolonged fasting. Conversely, individuals who were unable to complete the fasting month exhibited a shorter time since surgery, with most cases occurring within three to ten months postoperatively. According to the authors, this suggests that the early postoperative phases may present physiological challenges that limit fasting capability, due to ongoing metabolic adaptation, altered gastric capacity, or nutritional constraints.

Overall, these results emphasise the importance of adequate postoperative recovery prior to prolonged fasting. While individual variability exists, a minimum of 9-12 months post-surgery appears to be a critical threshold for improved fasting tolerance.

The outcomes related to GERD, revealed that the prevalence of GERD increases with time after surgery (Figure 2). The ≤3-months group had no reported GERD symptoms, indicating that the early post-surgical phases might not present significant reflux complications. However, as time progressed, GERD symptoms appeared more frequently, with a notable increase in the ≥12 months group, where a substantial proportion of patients reported GERD.

Figure 2: Prevalence of GERD at different durations since LSG. Data are expressed as the percentage (%) of patients reporting GERD in each group.

The authors suggests that long-term follow-up is essential for monitoring GERD symptoms in patients undergoing LSG, particularly beyond the first postoperative year. The increased prevalence at later intervals may be linked to anatomical changes in the gastric sleeve, alterations in oesophageal motility, or dietary habits. Further research is required to assess preventive strategies or medical interventions to manage GERD in post-bariatric patients.

There was also a correlation between the duration since surgery and the occurrence rate of three postoperative symptoms: GERD, vomiting and dumping syndrome (Figure 3). The substantial increase in the GERD prevalence in the ≥12-month group underscores the need for monitoring and potential medical or dietary interventions to mitigate discomfort and prevent complications.

Despite concerns regarding vitamin and mineral deficiencies during prolonged fasting, no instances of calcium, vitamin D, or vitamin B deficiencies were observed in the study population. Furthermore, dehydration, a common concern during extended fasting, did not lead to hospitalisation in any of the cases. This outcome probably reflects adequate hydration practices among participants and that when patients adhere to proper nutritional guidelines, they can maintain adequate micronutrient levels, even during fasting.

Figure 3: Prevalence of GERD, vomiting, and dumping syndrome at different durations since LSG in patients who completed fasting. Data are expressed as percentage (%) of patients.

The analysis of sex and age differences in symptoms among patients who successfully completed Ramadan fasting after bariatric surgery revealed notable trends (Figure 4). The sex-based comparison indicates that the prevalence of GERD, vomiting and dumping syndrome varies between males and females, with some symptoms appearing more frequently in one sex.

Figure 4: Frequency of postoperative complications (GERD, vomiting, and dumping syndrome) by patient gender and age group. The top panels (a-c) compare the incidence of these conditions between female and male patients. Concurrently, the bottom panels (d-f) display the age-based distribution across five groups, distinguishing between patients. Data are expressed as count (n).

This suggests potential physiological or behavioural differences in postsurgical responses to fasting. Additionally, the age-based distribution highlights the fact that symptoms are not uniformly experienced across different age groups. Older patients, particularly those above 40 years, exhibit a higher frequency of symptoms compared to younger individuals, which may be attributed to reduced physiological adaptation or pre-existing health conditions. The findings emphasise the importance of individualized medical guidance for post-bariatric patients observing fasting, considering both sex and age-related variations in symptom occurrence.

Analysis of prior fasting experience and its impact on fasting completion among post-bariatric surgery patients revealed a notable relationship. The study results demonstrate that individuals with previous fasting experience were more likely to successfully complete the full month of Ramadan fasting than those without such experience. Therefore, a familiarity with fasting, including its physiological and behavioural adaptations, may play a crucial role in postsurgical fasting success. Patients who had not fasted before bariatric surgery exhibited a higher rate of incomplete fasting, possibly due to a lack of prior metabolic conditioning or difficulties in managing dietary intake during prolonged fasting hours.

“The findings revealed that fasting completion rates were significantly influenced by the time elapsed since surgery, with patients who underwent LSG 12 months or more before Ramadan having the highest success rates. GERD prevalence increased with time after surgery, particularly in the ≥12-month group, whereas vomiting and dumping syndromes exhibited a more stable pattern over time...” the researchers concluded. “Prior fasting experiences positively impacted fasting completion rates. These findings have clinical implications for preoperative counselling and postoperative dietary guidance, particularly for patients seeking to safely observe Ramadan fasting after LSG. This study highlights the importance of adequate postoperative recovery, long-term symptom monitoring and individualised medical guidance for post-bariatric patients during Ramadan fasting.”

The findings were reported in the paper, ‘Navigating Ramadan Fasting Following Laparoscopic Sleeve Gastrectomy: Clinical Insights and Patient Experiences’, published in Cureus. To access this paper, please click here