Angela J Braun Jarrar AH Beasley JM Ohuma
Angela J. Braun Jarrar AH, Beasley JM, Ohuma EO, et al. Effect of high fiber cereal intake on satiety and gastrointestinal symptoms during Ramadan. Nutrients. 2019; 11(4): 939. doi: 10. 3390/nu 11040939.
Ramadan - a holy month ◦ 9 th month of Islamic [lunar] calendar 1/ Hijri 2 ◦ Starts 11 days earlier each year ◦ Muslims fast during sunlight hours ◦ 11 -16 hours; 29 -30 days 1 ◦ Tentatively begins April 23 rd 3 -24 th 1, 2020 ◦ Exemptions 1, 4 ◦ Pregnant/nursing/menstruating women ◦ Sick/ Elderly/ young children ◦ Travelers ◦ Expiation
The Ramadan Eating Pattern ◦ Sohor/ Suhur 1 ◦ The pre-dawn meal ◦ Followed by prayer ◦ May go back to bed ◦ Iftar – “Breaking the fast” 1 ◦ Eaten after sunset ◦ Typically a small portion of dates & water ◦ Snack/ appetizer ◦ Followed by prayer ◦ More substantial dinner
Background from the authors ◦ Dietary Fiber (DF) ↑ satiety ◦ Gel formation, Bulking & viscosity changes of gastric contents ◦ Gastric motor function modulation ◦ Blunting PPBG, insulin responses ◦ Lower energy density ◦ May affect palatability; ↓ energy intake ◦ Regular breakfast cereal consumption; ↓ BMI, & CVD/ DM risk ◦ Ready-to-eat cereals, oats, porridge & muesli 5 ◦ NOT exclusively high-fiber (HF)5 ◦ Lack of research ◦ HF cereal & GI symptoms ◦ Ramadan & GI symptoms
Background from the authors ◦ Two meals/day ◦ Body weight ◦ Energy balance ◦ Biological parameters ◦ High in protein & fat ◦ Ramadan-associated GI issues ◦ Indigestion/ Bloating ◦ Gastric reflux ◦ Dry mouth/ dysgeusia ◦ Epigastric pain ◦ Constipation ◦ Nausea/ vomiting
Statement of Purpose Original aim/ Primary outcome: “The aim of this study was to assess the effect of high fiber cereal on increasing satiety and as a result facilitating weight reduction” Current aim/ Secondary outcomes: “The current study aimed to assess the effect of high fiber cereal consumption on satiety, nutrient and energy intake, lipid profile, and glycemic responses and gastrointestinal symptoms during Ramadan”.
Recruit • Face-to-face interviews (not clear) • Posters: United Arab Emirates University (UAEU) • Email • Verbal/ written info sheets • Project aims, data needed & duration Consent • Signed consent & Approved by UAEU Screen • Participant questionnaire • Medical Hx/ Rx use & current health status
Inclusion ◦ Students/ Staff of UAEU ◦ Ages 18 -65 y/o ◦ BMI 18. 5 -30 kg/m 2 ◦ Fasted throughout Ramadan ◦ No objection to Sohor intervention (HF cereal) Exclusion ◦ Chronic Disease ◦ Heart ◦ HTN ◦ Renal Failure ◦ Liver ◦ Diuretics/ Laxatives ◦ Pregnant/ Lactating women
Research Methods ◦ Sample size determined to detect a 1. 5 ± 2. 2 kg wt loss ◦ N = 68 for power of 80% (β = 0. 20) ◦ RAND function of MS Excel used to randomize ◦ Statistical significance assessed at the 5% level -value <0. 05) ◦ All analyses used STATA v 11. 2 (p
◦ N = 45; intervention ◦ 90 g high fiber cereal at Sohor, daily (11 g DF; 60 g CHO, 10. 5 g Pro, 2. 8 g Fat) The Study Design ◦ N = 36; control ◦ Habitual diet maintained ◦ 20 -day long intervention (June 2016) ◦ Began on the 3 rd day of Ramadan ◦ Baseline (day 0) & endpoint (day 20) measurements collected Two-arm randomized, controlled, single-blinded, parallel-design
Research Methods ◦ Anthropometrics taken 3 x & averaged ◦ Body weight (nearest 0. 01 kg); minimal clothes/ no shoes ◦ Body composition; In. Body 720 analyzer ◦ Waist circumference; measuring tape ◦ 3 -day food records (baseline & endpoint) ◦ 2 weekdays, 1 weekend day ◦ The Food Processor v 10. 4 ◦ Kuwaiti Food Composition Database
Research Methods ◦ GI symptom frequency questionnaire ◦ bowel habits/ movement, constipation, vomiting, bloating, & heartburn ◦ Equilateral 3 -point satiety rating scale ◦ -3 = hungry/ having a strong desire for food 0 = neutral +3 = satisfied/ feeling of fullness ◦ Measurements taken at baseline & endpoint ◦ Only provided endpoint data ◦ Differences between groups
Research Methods ◦ Blood samples; after 12 hrs of fasting ◦ Fasting blood glucose ◦ Triglycerides ◦ Total cholesterol, LDL-chol. & HDL-chol. ◦ Data collection at baseline & endpoint ◦ Cobas C 111 automated biochemical analyzer
Body weight & BMI ↓* 0 Attrition N = 81 *Independent of HF cereal intervention
↑ Carbohydrate & Fiber intake
Bowel habits ↑ & Bloating ↓* *NOT reflective of baseline GI symptoms
Satiety ↑* Immediately at wake up 15 min after Sohor At 12: 00 pm *NOT reflective of baseline satiety ratings
Total Chol. ↓ & less LDL Chol. ↑
Value of the Study ◦ Not well controlled ◦ Physical activity ◦ Fluid status prior to blood tests ◦ Sohor meal time (sunrise 5: 27 am in 6/2016)6 ◦ Test/procedure standardized, reliable & valid? ◦ Anthropometrics; x 3 averaged ◦ Equilateral 3 -point satiety rating scale; validated 7 ◦ GI symptom questionnaire NOT validated ◦ Not clear what “Bowel habits increased” means
Value of the Study ◦ Key outcomes are theoretically linked to nutrition intervention ◦ ↑ satiety, ↓ energy intake & wt reduction ◦ DF known to positively affect BM ◦ Adequate sample size to detect significant result? ◦ Goal was met; n = 81 > 68 needed for 80% power analysis ◦ Good study Design? ◦ Two-arm randomized, controlled, single-blinded, parallel study ◦ Could have been double-blinded to ↓ researcher bias
Value of the Study ◦ Methods of Dietary Assessment ◦ 3 -day food record w/ portion size photos ◦ The Food Processor (v 10. 4, not latest version in 2016)8 ◦ Kuwaiti Food Composition Database - validated? ◦ The Arabic Food Composition Database 9 for myfood 24; developed 2019 ◦ Randomization inadequate ◦ Baseline characteristics were not compared ◦ No dropouts – per protocol analysis
Value of the Study ◦ Relevant Outcomes reported ◦ Primary outcome: weight reduction ◦ Secondary outcomes: satiety, bowel habits, body composition, blood glycaemia/ lipidemia ◦ Changes in GI symptoms from baseline (not reported) ◦ Not truly Blinded? ◦ Participants knew the aims; intervention was obvious ◦ Eligibility criteria appropriate? ◦ BMI range (18. 5 -30 kg/m 2) too narrow; excluded obese ◦ Compliance was not mentioned
Value of the Study ◦ Groups treated equally apart from intervention ◦ Groups not compared at baseline ◦ Uneven groups (5 males in control; 0 in intervention) ◦ Sample not representative of UAE; Male: Female ~2. 5: 110 ◦ Complete follow up? & Was the study long enough? ◦ 100% follow up ◦ Length of study questionable ◦ Intend-to-treat analysis not mentioned prior to randomization ◦ Funded by Kellogg EMEA (Europe Middle East Africa)
Authors conclusions ◦ HF cereal intervention ◦ ↑ Satiety ◦ ↓ Bloating ◦ Improved bowel movements ◦ Positively maintained total chol. & LDL-chol. levels ◦ No change: BG, HDL chol. & TG ◦ Short study length ◦ Healthy participants vs. HLD/ DM etc.
My conclusions ◦ Agree w/ satiety recommendations ◦ GI symptom results inconclusive ◦ GI symptom baseline not reported ◦ Pt knew the aims ◦ Healthy participants v. Obese/ HLD/ DM
Practical implications ◦ Islam is the fasted growing religion across the globe 11 ◦ Optional days to fast, apart from Ramadan fasting 12 ◦ Fasting is becoming increasingly popular ◦ Supports the ANDs recommendation to incorporate HF meals during Ramadan for improved satiety 13 ◦ More research & continued education
Additional Sources 1. Ramadan Information Sheet from Islamic Networks Group (ING). https: //ing. org/ramadan-information-sheet/. Accessed February 19, 2020. 2. Islamic Calendar 2020 - Hijri Calendar 2020 Events Holidays. Islamic. Finder. https: //www. islamicfinder. org/islamic-calendar/2020/? type=Gregorian. Accessed February 19, 2020. 3. Ramadan 2020. Islamic. Finder. https: //www. islamicfinder. org/special-islamic-days/ramadan-2020/. Accessed February 19, 2020. 4. Haleem O, Haleem A. Valid Exemptions for Not Fasting Ramadan. Zakat Foundation of America. https: //www. zakat. org/en/valid-exemptions-for-not-fasting-ramadan/. Published June 4, 2018. Accessed February 19, 2020. 5. Williams PG. The benefits of breakfast cereal consumption: a systematic review of the evidence base. Adv Nutr. 2014; 5(5). doi: 10. 3945/an. 114. 006247. 6. Dubai, United Arab Emirates - Sunrise, Sunset, and Daylength, June 2016. timeanddate. com. https: //www. timeanddate. com/sun/united-arab-emirates/dubai? month=6&year=2016. Accessed February 25, 2020. 7. Holt SH, Miller JC, Petocz P, et al. A satiety index of common foods. Eur J of Clin Nutr. 1995; 49(9): 675 -690.
Additional Sources 8. Food Processor 11. 1. x (Released June 2016). ESHA Research. https: //esha. zendesk. com/hc/en-us/articles/208821746 Food-Processor-11 -1 -x-Released-June-2016 -. Accessed February 25, 2020. 9. Kalendar S, Bawajeeh A, Hancock N, et al. Developing a new Arabic Food Composition Database for an Online Dietary Recall Tool-myfood 24. Obesity Abstracts. http: //www. obesity-abstracts. org/ob/0001/ob 0001 p 56. Published September 4, 2019. Accessed February 24, 2020. 10. Langton, James. “Men Outnumber Women Three to One as UAE Population Soars Past Nine Million. ” The National, 4 Aug. 2017, www. thenational. ae/uae/government/men-outnumber-women-three-to-one-as-uaepopulation-soars-past-nine-million-1. 616790. 11. Lipka M. Muslims and Islam: Key findings in the U. S. and around the world. Pew Research Center. https: //www. pewresearch. org/fact-tank/2017/08/09/muslims-and-islam-key-findings-in-the-u-s-and-around-the-world/. Published August 9, 2017. Accessed February 23, 2020. 12. Optional Fast. Al. https: //www. al-islam. org/fast-month-ramadhan-philosophy-and-ahkam-yasin-t-al-jibouri/optional-fast. Published October 16, 2013. Accessed February 23, 2020. 13. Elnakib S. Ramadan The Practice of Fasting. Eat. Right. https: //www. eatright. org/health/lifestyle/culture-andtraditions/ramadan--the-practice-of-fasting. Published June 15, 2017. Accessed February 24, 2020.
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