NAFLD is a rapidly emerging epidemic, leading to the search for cost-effective routes to prevent metabolic syndrome and NAFLD as well as the progression into cirrhosis and hepatoma.
The initial diagnosis of NAFLD in clinical practice depends on the laboratory findings and radiological imaging techniques in the absence of other causes of fatty liver [16]. Recently, attention has been focused on transient elastography, which is a non-invasive ultrasound-based method that uses shear wave velocity to assess the stiffness of liver tissue. Depending on the physical characteristics such as the velocity and intensity attenuation of the shear wave, the acquired data are processed and presented as LSM and CAP.
On the other hand, simple blood-based scores can be easily obtained as NAFLD fibrosis score (NFS) [15], which has shown high sensitivity for detecting advanced fibrosis [17]. Additionally, FIB-4 is a simple, inexpensive, and non-invasive test that can be easily obtained to determine the degree of hepatic fibrosis [18]. In the present study, transient elastography for the measurement of CAP and LSM was performed. Also, FIB4 and NFS were also calculated.
Most of the studies evaluated the changes of some clinical, biological, and anthropometric factors among metabolic syndrome, diabetic, hyperlipidemia patients; cardiovascular patients; and/or healthy adults [19,20,21,22].
Our study demonstrates that there is a statistically significant decrease in body mass index, fasting blood glucose, and HbA1c; this finding does not agree with M’guil et al.’s results that investigate the lack of effect of Ramadan fasting on blood glucose in type 2 diabetes patients [23]. But our study agrees with the study of Ebrahimi et al. that revealed a significant improvement in anthropometric measures as well as fasting glucose, plasma insulin, and insulin resistance [24]. Also, it differs from a study by Nematy et al. showing that there is no difference in insulin and FBS after Ramadan fasting [19].
Our study illustrates there is a statistically significant decrease in triglycerides, LDL cholesterol, total cholesterol, serum albumin, and total protein. But in some studies, an increase in plasma cholesterol and TG and a decrease in SBP were shown but in the healthy population [19, 25, 26].
Our study shows that there is a statistically significant increase in HDL cholesterol. The evidence that an obvious increase in plasma HDL-C occurs after Ramadan fasting is promising, as observed in some studies [26,27,28].
Our study demonstrates that there is a statistically significant decrease in AST, ALT, and alkaline phosphatase after Ramadan fasting. The ALT enzyme decreases significantly after Ramadan in the present study that was along with Unalacak et al.’s findings [29], and Arabi et al.’s study on 50 NAFLD patients revealed that Ramadan fasting was associated with decreased serum insulin, ALT level, and systolic and diastolic blood pressure, with an increase in HDL-C after an average of 27 days of fasting [10]. Also, in a previous study, lifestyle change and losing at least 5% of body weight have a significant improvement on ALT enzyme in NAFLD patients [30].
However, in other studies, there is no significant change in ALT or AST enzymes [11, 31]. Also, Rahimi et al. reported an increase in ALT levels after Ramadan fasting in NAFLD patients [32].
Our study demonstrates that there is a statistically significant improvement after Ramadan fasting in FIB-4, CAP, and LSM. However, there is a non-significant change in NFS, so we suggest that Ramadan fasting could improve the liver condition in patients with NAFLD proved with a significant reduction in the CAP and LSM. This agrees with the dietary regimen used to reduce weight for both lean and obese NASH patients and found significant improvement in histopathology in both groups 1 year after weight reduction [33].
On the other hand, there is a statistically non-significant change in ultrasonographic grading of fatty liver before and after Ramadan fasting during the short duration of this study. This is not in agreement with that Ramadan fasting was found to improve liver steatosis as measured by ultrasound grading in NAFLD patients in the study of Aliasghari et al. [34].
Our study included 2 patients with hypothyroidism; this is not enough to relate between hypothyroidism and NAFLD. Although the meta-analysis of He et al. showed strong epidemiological evidence for the significant relationship between hypothyroidism and NAFLD, patients with hypothyroidism either subclinical or overt are at a higher risk for development of NAFLD than those with normal thyroid function [35].
The strength of our study is that this is the first prospective study for the effect of Ramadan fasting on hepatic steatosis as quantified by controlled attenuation parameter (CAP). Certain limitations of our study are that our study is observational and has a relatively small sample size, which might limit the generalizability of the result. Further studies are recommended to confirm this study’s results after excluding other comorbidities, e.g., hypothyroidism.
In conclusion, our results showed an improvement of FibroScan and biochemical parameters of patients with NAFLD after Ramadan fasting, and this study suggested that Ramadan fasting may be effective in improving the liver steatosis in NAFLD patients. Further studies with a large sample are recommended to confirm our results and approve fasting as a potential treatment for NAFLD.