Intermittent Fasting in Sickle Cell Disease: Case series and Review of Literature
Authors: Syed Raabia , Rizvi Insia , Hussain Faiz , Farooqui Marwah 
Published: June 2024

Abstract

Presentation Date: 6/8/2024
Presentation Start Time: 6:00:00 PM

Background
Sickle cell disease (SCD) is a genetic hematological illness, morphing a normal red blood cell (RBC) into a distinct sickle shape, awarding it its name. This illness can present with a multitude of symptoms, affecting millions of individuals worldwide. Lifestyle is a known contributor to the overall course of the disease and recent studies have reported normal BMI and exercise as protective factors for SCD and vaso-occlusive pain episodes (VOE). Various religious emphasize fasting around the world. For this study’s purpose, a broad definition of fasting was adopted to include all types of intermittent fasting—including complete abstinence from food and/or water for a set time period usually lasting several hours. The specific aim of this study was to determine if intermittent fasting has any impact on the course of sickle cell disease specifically with respect to VOE.

Methods
We describe a case series of 4 patients at our sickle cell center who observed intermittent fasting between January 2020-December 2023. Additionally, we conducted a comprehensive computerized literature research to identify studies analyzing lifestyle modifications for SCD using PubMed National Library of Medicine database from 1998-2023, involving both medical subject heading (MeSH) terminology and relevant keywords for search strings. The following items were used to search for the studies: “lifestyle modifications,” “fasting,” “body mass index,” “exercise,” hematology,” and “SCD.” We performed this research to further the knowledge of the impact of intermittent fasting on sickle cell disease course.

Results
In our case series we noted patients with higher hemoglobin level had the least VOE related hospital/emergency room encounters. Table 1 shows the demographics and characteristics of the patients in our case series. Patients with a lower BMI had lower total bilirubin (TB) and less healthcare utilization. Patients with higher number of ED visits/hospitalizations had higher WBCs, TB, and BMI. There was no clear correlation between worsening VOE or increased healthcare utilization in patients who were practicing intermittent fasting. In our cohort, there was one patient who was unable to fast as intended for a consecutive 28-30 days due to dehydration, VOE, and frequent hospitalizations. The other 3 patients could observe intermittent fasting without exacerbation of their disease.
Throughout the reviewed articles and studies, differences in findings were evident based on the form of fasting with mixed results in regards to the impact of fasting on SCD course. The countries in the Arabian Sea follow similarly to the 16/8 fasting model causing worsening SCD leading patients to obtain medical attention. The lack of protein in the diet of Catholics and Hindus has caused complications from SCD leading to alternate forms of deficiencies, depriving cells of much needed nutrients. For South Asian women who are already at greater risk for iron-deficient anemia, effects of fasting with SCD alters platelet count, reticulocytes count, and creatinine level. The Mormon Church observes 24-hour fasts, which when prolonged, can cause severe effects in patients with SCD. A recent study by Ahmed et al in 52 Arab sickle cell patients, showed that intermittent fasting did not influence the rate of VOE but was associated with lower platelet count, reticulocytes count, and creatinine level. The conclusion for these multiple studies reveals that the effect on the different forms of intermittent fasting does not play a significant role in symptoms of SCD. While some specific areas such as the Middle East might see increases in ER visits during fasting throughout Ramadan, there is not conclusive evidence that fasting has a direct negative effect on SCD specifically in our case series.

Conclusions
A variety of religious practices for fasting may impact the SCD course. It is important for sickle cell providers to be aware of their patient’s lifestyle practices helping them maintain good health while fasting. Whether it be intermittent forms of fasting or continuous based on religions, this information can provide some guidance for sickle cell providers who encounter patients that implement fasting practices. Other chronic diseases have responded positively to fasting without serious adverse effects. However, for SCD, we have yet to determine whether it can contribute positively or negatively. While a lower BMI and improved hematologic markers are apparent in individuals who practice fasting, further studies are needed to determine if the improved inflammatory profile enhances the sickle cell disease course.
Interpretation