Exercise Training and Fasting: Current Insights

Figures & data

Table 1 PICOS Criteria

PICO Title	Description
Population	Healthy Sedentary Human, Untrained, Trained
Intervention	Fasting, Physical Training
Comparison	Control Intervention, No Intervention
Outcomes	Health Indices, Physical Performances
Study Design	Randomized Controlled Trial

Table 3 Effect of Alternate Day Fasting on Body Composition

Author	Study Population	Study Design	Main Findings
Oh et al (2018)^Citation30	45 overweight and obese (26 Females −19 Males): -ADCR, n=13 -Exercise, n=10 -Exercise + ADCR, n=12) -CG, n=10 Age: 18 to 64 years. BMI: > 23.0 kg/m^2.	For 8 weeks Exercise-ADCR and ADCR groups: → 3 Alternately fasted days (25% of daily energy intake, food consumed between 12 pm and 2 pm) → 4 Feed days (ad libitum)	In ADCR group a significant reduction in: ↓ Body weight:-2.4 ± 3.1 kg (p<0.05) ↓ BMI: −0.9 ± 1.3 kg/m^2 (p<0.05) ↓ Waist circumference: −2.2 ± 3.6 cm (p<0.05) ↓ Percent of body fat: −1.3 ± 2.4% (p<0.05).
Trepanowski et al (2017, 2018)^Citation18,Citation31	100 obese adults (86 Females- 14 Males): - ADF, n=34 - CR, n=35 - CG, n=31 Age: 18 to 64 years BMI: ± 34	For 1 year (6-month weight-loss + 6-month weight-maintenance): →ADF: 25% of energy needs on fast days; 125% of energy needs on alternating “fast days” →CR: 75% of energy needs every day →CG: no-intervention	↓ Fat free mass/total mass in both ADF (0.03 ± 0.00) and CR (0.03 ± 0.01) compared to the control group (P<0.01). NS differences between the intervention groups.
Catenacci et al (2016)^Citation36	26 adults with obesity (19 Females- 6 Males): -ADF, n=14 -CR, n=12 Age: 18–55 years. BMI ≥30 kg/m^2.	For 8 weeks → ADF: alternate between fasting days (zero-calorie) and ad libitum feeding days. → CR: ↓−400 kcal/day	NS differences in Weight and Body composition between ADF and CR groups. In ADF group: ↓ Body weight: 94.8 ± 4.4 to 86.5 ± 4.4 kg (p < 0.001). ↓ BMI: 35.8 ± 1.4 to 33.6 ± 1.4 kg/m^2 (p<0.001). ↓ Fat mass: 37.3 ± 2.6 to 33.9 ± 2.5 Kg (p<0.001). ↑ Lean mass: 35.2 ± 2.8 to 50 ± 2.7 kg (p<0.001).
Varady et al (2013)^Citation35	32 normal-weight and overweight (22 Females- 8 Males): - ADF, n=15 -CG, n=15 Age: 35 to 65 years BMI: 20 to 29.9 kg/m^2	For 12 weeks →ADF group alternated between fasting days (25% of kcal needs as determined by Mifflin equation; consumed between 12 pm and 2 pm) and ad libitum feeding days.	↓ Body weight −5.2 ± 0.9 kg (P<0.001) ↓ Body fat −3.6 ± 0.7 kg (P<0.001) NC in fat free mass
Klempel et al (2013)^Citation39	32 obese women: -ADF-HF, n=17-ADF-LF, n=18 Age: 25–65 years. BMI: 30 to 39.9 kg/m^2	For 8 weeks Alternated between fasting days (25% of kcal needs as determined by Mifflin equation; consumed between 12 pm and 2 pm) and ad libitum feeding days. The two diets: →ADF–HF (45% fat, 40% carbohydrate and 15% protein), →ADF–LF (25% fat, 60% carbohydrate and 15% protein).	↓ Body weight (P<0.0001) −4.3±1.0 kg in the ADF–HF and −3.7±0.7 kg in ADF–LF group. ↓ Fat mass (P<0.0001) −5.4±1.5 kg and −4.2±0.6 kg in the ADF–HF and ADF–LF groups respectively. NC in Fat free mass (ADF–HF: 1.1±1.3 kg; ADF–LF: 0.5±0.7 kg).
Bhutani et al (2013)^Citation32	83 obese (80 Females - 3 Males) -E-ADF, n = 18 -ADF, n = 25 -Exercise, n = 24 -CG, n = 16 Age: 25 to 65 years BMI: 30 to 39.9 kg/m^2	For 12 weeks →ADF and E-ADF groups alternated between fasting days (25% of kcal needs as determined by Mifflin equation; consumed between 12 pm and 2 pm) and ad libitum feeding days.	In ADF: ↓Body weight: 94 ± 3 to 91 ± 3 kg (p<0.001). ↓BMI: 35±1 to 34±1 kg/m^2 (p<0.001). ↓Waist circumference: 100 ± 2 to 95 ± 2 cm (p < 0.001). ↓Fat mass: 43 ± 2 to 41 ± 2 kg (p=0.008). ↓Fat free mass: 51 ± 2 to 50 ± 2 kg (p=0.03).
Eshghinia & Mohammadzadeh (2013)^Citation33	15 overweight and obese women. Age: 33.46 ± 5.9 years. BMI: 33.16 ± 5.02 kg/m^2.	For 6 weeks, On 3 weekly fasting days; Saturday, Monday, and Thursday (25%– 30% of energy needs) On 4 feeding days (1700–1800 kcal/d)	↓Body weight: 84.3 ± 11.4 to 78.3 ± 10.2 kg (P<0.001). ↓BMI: 33.16 ± 5.02 to 30.72 ± 4.62 kg/M^2 (P<0.001). ↓Fat mass: 45.82 ± 4.16 to 42.98 ± 4.01% (P<0.001).
Varady et al (2011)^Citation40	59 overweight and obese (50 Females- 9 Males): ADF, n=13 CR, n=12 Exercise, n=12 Control, n=12 Age: 35 to 65 years BMI: 25 to 39.9 kg/m^2	For 12 weeks: ADF and E-ADF groups alternated between fasting days (25% of kcal needs as determined by Mifflin equation; consumed between 12 pm and 2 pm) and ad libitum feeding days.	↓ Body weight (P<0.001) in: ADF: −5.2 ± 1.1% CR: −5.0 ± 1.4% EX: −5.1 ± 0.9%
Varady et al (2009)^Citation34	60 obese (12 Females, 4 Males) Age: 35–65 years. BMI: 30 to 39.9 kg/m^2.	For 8 weeks: Alteration between fasting days (25% of kcal needs as determined by Mifflin equation; consumed between 12 pm and 2 pm) and ad libitum feeding days.	↓ weight −5.6 ± 1.0 kg (P<0.001) ↓ Body fat-5.4 ± 0.8 kg (P<0.01)

Abbreviations: ADCR, Alternate Day Caloric Restriction ADF, Alternate Day Fasting; ADF-HF, Alternate Day Fasting with High Fat ADF-LF, Alternate Day Fasting with Low Fat; BMI, Body Mass Index; CR, Caloric Restriction; E-ADF, Exercise With Alternate Day Fasting; EX, Exercise; n, number; NC, No Change; NS, Non-Significant.

Table 2 Intermittent Caloric Restriction and Body Composition

Author	Study Population	Study Design	Main Findings
Schübel et al (2018)^Citation29	150 overweight and obese (50% Males – 50% Females): - CCR, n=49 - ICR, n=49 - CG, n=52. Age: 35 to 65 years. BMI: 25 to 40 kg/m^2.	→ICR: 5 days without energy restriction and 2days with 75% ↓ in energy needs → CCR: 20% daily ↓ in energy needs →CG: NC in calorie intake (12 weeks intervention phase((12 weeks maintenance phase)) 26 weeks follow-up phase).	Body weight during intervention phase: ↓ ICR: 7.1%±0.7% (P<0.001) ↓CCR: 5.2%±0.6% (P=0.053). ↓ CG:3.3%±0.6% (NS) At the final follow-up assessment (week 50), weight loss was ↓ ICR: 5.2%±1.2% (P=0.01) ↓ CCR: 4.9%±1.1% (P=0.89) ↓ CG:1.7% ± 0.8% (NS)
Fitzgerald et al (2018)^Citation28	31 subjects with multiple sclerosis(7 Males - 24 Females): - DCR, n=11 -ICR, n=11 -CG, n=9. Age: 18 to 50 years. BMI: 23 to 29.9 kg/m^2.	For 8 weeks: →DCR: 22% daily ↓ in energy needs → ICR:75% ↓ in energy needs for2 days/week and 0% ↓for 5 days/week →CG:NC in energy needs.	NS weight changes in the ICR group
Teng et al (2013)^Citation25	56 Men: - FCR, n=28 - CG, n=28. Age: 50 to 70 years. BMI: 23 to 29.9 kg/m^2.	For 12 weeks: → FCR: 300–500 kcal/d↓ in caloric intake (For 2 non-consecutive days per week). →CG: NC in energy needs	A significant interaction effect in →Body weight (P<0.001) →BMI (P<0.01) →Fat percentage (P<0.001) →Fat mass (P<0.05). All these variables ↓ in the FCR group
Hussin et al (2013)^Citation24	32 healthy males: - FCR, n=16 - CG, n=16 Age: 59.7±6.3 years BMI: 26.7 ± 2.2 kg/m^2	For 12 weeks: → FCR: 300–500 kcal/d ↓ in caloric intake (For 2 non-consecutive days per week). →CG: NC in energy needs	In FCR group: ↓ Body weight: −3.8% (74.2 ± 7.8 kg to 71.4 ± 7.2 kg) (P=0.000) ↓BMI: −3.7% (26.7 ± 1.8 to 71.4 ± 7.2) (P=0.043) ↓Percent body fat: −5.7% (26.4 ± 2.4% to 24.9 ± 2.5%) (P=0.001).
Klempel et al (2012)^Citation26	54 obese women: - IFCR-L, n= 28 - IFCR-F, n=26 Age: 35 to 65 years BMI: 30 to 39.9 kg/m^2	For 8 weeks: →6 days each week anisocaloric diet with a 30% energy restriction →24 hFasting (120 kcal intakes from juice powder).	↓Body weight(P=0.04): IFCR-L group (3.9 ± 1.4 kg) versus IFCR-F group (2.5 ± 0.6 kg). ↓Fat mass (P<0.0001): IFCR-L (2.8 ± 1.2 kg) versus IFCR-F (1.9 ± 0.7 kg).
Teng et al (2011)^Citation27	25 healthy men: -FCR, n=12 -CG (n=13) Age: 58.8±5.1 years BMI: 23.0 to 29.9kg/m^2	A three-month clinical trial on CR (↓ of 300 to 500 kcal/day) combined with two non-consecutive days/week of fasting (FCR)	In the FCR ↓Body weight: −3.14% (71.6 ± 6.0 to 69.3 ± 6.0 kg) (P<0.001) ↓Body fat: −6.35% (26.4 ± 3.9 to 25.3 ± 3.8 kg) (P<0.05) ↓Fat-free mass: −0.9% (P<0.05)

Abbreviations: BMI, Body Mass Index; CCR, Continuous Caloric Restriction; CG, Control Group; CR, Caloric Restriction; DCR, Daly Caloric Restriction; FCR, Fasting Caloric Restriction; ICR, Intermittent Caloric Restriction; IFCR-F, Intermittent Fasting Caloric Restriction food based; IFCR-l, Intermittent Fasting Caloric Restriction Liquid based; n, number; NS, Non-significant.

Table 5 Effects of Ramadan Fasting on Body Composition

Authors	Study Population	Main Findings
Alsubheen et al (2017)^Citation47	17 healthy males: →FG: n=9, Age: 32.2 ± 7.8 years →NFG: n=8, Age: 35 ± 9.4years.	↓ Body mass and adiposity (P< 0.05) NC in lean mass
Nugraha et al (2017)^Citation51	50 healthy males: →FG: n=25, Age: 26.12 ± 0.98 years →NFG: n=25, Age: 26.2 ± 0.98 years	↓Body weight (p<0.001) ↓Body mass index (p<0.001) ↓Skeletal muscle mass (p<0.01) ↓ Fat free mass (p<0.01)
Aliasghari et al (2017)^Citation37	83 patients with NAFLD (57 Males – 26 Females): →FG: n=42, Age: 37.59 ± 7.06 years →NFG: n=41, Age: 35.8 ± 7.33 years.	↓Body weight, ↓BMI, ↓Waist and hip circumferences, ↓Waist-to-hip ratio (P<0.001) ↓Body fat percentage in males (P=0.31) and female (P=0.4)
Latiri et al (2016)^Citation49	29 healthy males Age: 27 ± 1 years	NS effect on weight (P=0.98) or BMI (P =0 0.97)
Sezen et al (2016)^Citation52	70 healthy men Age: 37±7 years	↓BMI, ↓Waist-Hip ratio, ↓Body water rate, ↓Body fat mass, and ↓Visceral fat mass (p<0.05 each)
Gnanou et al (2015)^Citation53	20 healthy men Age: 19–23 years.	↓ Body weight (2.4%, p < 0.001) ↓ Body mass index (5.5%, p < 0.01)
Hammouda et al (2014)^Citation54	12 males, professional soccer players Age 17.52 ± 0.2 years	↓Body mass (P<0.001) ↓Fat mass (P<0.01)
Hammouda et al (2013)^Citation55	15 males, professional soccer players Age: 17.3 ± 0.3 years	↓Body mass (P< 0.05) ↓ Fat mass (P<0.05).
Bouhlel et al (2013)^Citation56	20 trained men: →FG, n=10 →NFG, n=10 Age: 21.8 ± 1.9 years	↓Body weight (P < 0.001) ↓BMI (p < 0.01) ↓Fat mass percentage (P<0.03).
Zarrouk et al (2013)^Citation57	8 trained males karate players Age: 17.2± 0.5 years	NC
Mirzaei et al (2012)^Citation58	14 males collegiate wrestlers Age: 20.12±2.5 years	↓ Body mass (P=0.001) ↓Fat free mass (P=0.019) ↓Fat percentage (P=0.001)
Racinais et al (2012)^Citation38	11 males Age: 31 ± 3 years	NC
Kacimi et al (2012)^Citation59	50 healthy subjects (21 Males aged: 18–49 years and 29 females aged: 18–51 years)	↓ Body weight (P<0.01) ↓BMI (P<0.01) ↓ body fat percentage (P<0.01)
Trabelsi et al (2011)^Citation60	18 active men →FG; n=10, Age: 26.6 years →NFG; n=8, Age: 27.2 years	↓Body weight −1.9% (P<0.001) ↓Body fat percentage −6.2% (P=0.003) In NFG: ↑Body weight +2.2% (P<0.001) ↑ Body fat percentage +10.2% (P=0.001)
Güvenç (2011)^Citation61	16 male soccer players (Age: 17.4±1.2 years)	NS changes in body mass, percentage of body fat, fat-free mass ↓Skinfold thicknesses (p<0.05).
Asl (2011)^Citation46	15 male athletes Age: 20–25 years	↓Body weight, ↓BMI, ↓Free fat mass and ↓Body fat (P < 0.05).
Lotfi et al (2010)^Citation62	9 male resistance athletes Age: 23 ± 3 years	NS changes
Chennaoui et al (2009)^Citation63	8 male middle-distance athletes Age: 25.0 ± 1.3 years	NS changes
Chaouachi et al (2008)^Citation64	15 male elite judo athletes Age: 18 ± 1 years	↓ Body mass (P<0.001) ↓BMI (P<0.001) ↓Body fat (%) (P<0.05) ↓ Fat mass (P<0.05) NS modification in Fat free mass.
Meckel et al (2008)^Citation11	19 male soccer players Age: 14–16 years	↓sum of skinfolds (P<0.05). NS change in body weight.
Aksungar et al (2007)^Citation65	68 healthy males: →FG, n=40, Age: 20–39 years →NFG, n=28, Age: 20–40years	NS changes
Al-Hourani & Atoum (2007)^Citation66	57 students women	↓Body mass, ↓Body fat, ↓muscle mass, ↓body water, ↓BMI (P<0.05 each).
Karli et al (2007)^Citation9	10 male elite power athletes (2 wrestlers, 7 sprinters and 1 thrower) Age: 20–24 years	NS changes
Bouhlel et al (2006)^Citation67	9 trained men (Age: 19±2 years).	↓Body mass, ↓BMI, ↓Fat mass, ↓% Lean mass (P<0.01 each). NS change in hip and waist circumferences.
Lamine et al (2006)^Citation68	9 males, 21 females	NC
Yucel et al (2007)^Citation69	21 males, 17 females Age 20–45years.	NC
Ramadan (2002)^Citation70	16 sedentary adult male	NS changes
Ramadan et al (1999)^Citation71	13 healthy adult men.	NS changes

Abbreviations: BMI, Body Mass Index; FG, Fasting Group; NFG, Non Fasting Group; RF, Ramadan Fasting; n, Number; NC, No Change; NS, Non Significant.

Table 4 Effect of Time Restricted Feeding on Body Composition

Author	Study Population	Study Design	Main Findings
Moro et al (2016)^Citation42	34 resistance-trained males: -TRF, n= 17 -ND, n= 17 Age: 29.21 ± 3.8 years Weight: 84.6 ± 6.2 kg	For 8 weeks: →TRF: 100% of their energy needs in an 8-h each day → three meals at 1 p.m., 4 p.m., and 8 p.m. and fasting period = 16h (2826 ± 412.3 kcal/day, carbohydrates 53.2 ± 1.4%, fat 24.7 ± 3.1%, protein 22.1 ± 2.6%) →ND: 100% of their energy needs three meals consumed at 8 a.m., 1 p.m., and 8 p.m. (3007 ± 444.7 kcal/day, carbohydrates 54.7 ± 2.2%, fat 23.9 ± 3.5 %, protein 21.4 ± 1.8).	↓Fat mass (−16.4% TRF versus −2.8% ND) (p=0.0448). NC in Free fat mass.
Le Cheminant et al (2013)^Citation41	29 healthy men Age: 20.9±2.5 years BMI: 24.4±4.5 kg/m^2	→For 2 weeks: Night eating restriction intervention (elimination of energy intake from 19.00 to 06.00 hrs) →For 2 weeks: control condition, counterbalanced and separated by a 1-week washout period.	↓ Body weight −1% (P<0.05).
Soeters et al (2009)^Citation45	8 lean healthy men: -IF, n=8 -Standard diet, n=8 Age: 20 to30 years BMI: 18.2 to 24.7 kg/m^2	For 2 weeks 4h TRF every other day	NS changes
Stote et al (2007)^Citation43	69 healthy (14 Females −7 Males) Age: 40–50 years BMI: 18 to 25 kg/m^2	Two 8 Weeks treatment periods: all of the calories needed for weight maintenance in either 3 meals/d or 1 meal/d.	After 1 meal/d ↓Body weight −1.4 kg (p<0.05) ↓Body fat mass −2.1 kg, (P<0.05) NS differences in fat-free mass and total body water. NS change after 3 meals/d
Halberg et al (2005)^Citation44	8 healthy men Age: 25.0 0.1 years BMI 25.7 0.4 kg/m^2	For 14 day 4h TRF every other day. Each fasting period (22:00 to18:00 h the following day).	NS changes

Abbreviations: BMI, Body Mass Index; IF, Intermittent Fasting; ND, Normal Diet; TRF, Time Restricted Feeding; n, number; NC, No Change; NS, Non-Significant.

Table 6 Effect of Fasting on Metabolic Adaptations in Trained and Untrained Subjects

Author	Study Population	Study Design	Main Findings
			Lipid Metabolism	Glucose Metabolism	Protein Metabolism
Schübel et al (2018)^Citation29	150 overweight and obese (50% Male – 50% female) - CCR, n=49 - ICR, n=49 - CG, n=52. Age: 35 to 65 years. BMI: 25 to 40 kg/m^2.	→ICR: 5 days without energy restriction and 2days with 75% ↓ in energy needs→ CCR: 20% daily ↓ in energy needs →CG: NC in calorie intake (12 weeks intervention phase) (12 weeks maintenance phase) (26 weeks follow-up phase).	NS change	↓ The glucose for CCR compared with ICR (P< 0.01) (at week 12). NS difference between 3 groups (at week s 24–50)	NM
Oh et al (2018)^Citation30	45 overweight and obese (26 Females- 19 Males): -ADCR, n=13 -Exercise, n=10 -Exercise + ADCR, n=12) -CG, n=10 Age: 18 to 64 years. BMI: > 23.0 kg/m^2.	For 8 weeks Exercise-ADCR and ADCR groups: → 3 Alternately fasted days (25% of daily energy intake, food consumed between 12 pm and 2 pm) → 4 Feed days (ad libitum)	In ADCR group NS changes	In ADCR group NS changes	NM
Trepanowski et al (2017)^Citation18	100 obese adults (86 Females- 14 Males): - ADF, n=34 - CR, n=35 - CG, n=31 Age: 18 to 64 years BMI: ± 34	For 1 year (6-month weight-loss + 6-month weight-maintenance): →ADF: 25% of energy needs on fast days; 125% of energy needs on alternating “feast days” →CR: 75% of energy needs every day →CG: no-intervention	NS change in TC and TG. Just At month 6, ↑ HDL-C in ADF versus the daily CR (P<0.05) Just at month 12, ↑ LDL-C in the ADF group (P<0.05)	NS changes.	NM
Aliasghari et al (2017)^Citation37	83 patients with NAFLD (57 Males – 26 Females): -FG: n=42, Age: 37.59 ± 7.06 years -NFG: n=41, Age: 35.8 ± 7.33 years.	Ramadan fasting	NS changes	↓ Fasting blood glucose (P<0.01)	NM
Alsubheen et al (2017)^Citation47	17 healthy males: -FG: n=9, Age: 32.2 ± 7.8 years -NFG: n=8, Age: 35 ± 9.4years.	Ramadan fasting	NS change in TC	NS changes	NM
Bak et al (2016)^Citation79	18 healthy males -Lean, n=9, BMI:19 to 23 kg/m^2 -Obese, n=9, BMI: 32 to 40 kg/m^2 Age: 20 to 35 years	Examination on two occasions separated by a minimum of 21 days: 1) after an overnight fast of 12 h 2) after 72 h of fasting.	In obese: ↑ whole body lipolysis	↓ in glucose for both groups (P < 0.01)	Obese:↓ urea and amino acid fluxes both in the basal and 72-h fasted state. ↓ forearm muscle protein breakdown per 100 mL of forearm tissue, differences that persisted after 72 h of fasting
Syam et al (2016)^Citation80	43 volunteers (7 Males- 36 Females) Age: 34.19 ± 11.25 years BMI: 23.71 ± 3.96 kg/m^2	Ramadan fasting	NM	NM	NS change in Protein body mass (−0.049 ± 0.170 kg, P=0.561)
Moro et al (2016)^Citation42	34 resistance-trained males: -TRF, n= 17 -ND, n= 17 Age: 29.21 ± 3.8 years Weight: 84.6 ± 6.2 kg	For 8 weeks: →TRF: 100% of their energy needs in an 8-h each day → three meals at 1 p.m., 4 p.m., and 8 p.m. and fasting period = 16h (2826 ± 412.3 kcal/day, carbohydrates 53.2 ± 1.4%, fat 24.7 ± 3.1%, protein 22.1 ± 2.6%) →ND: 100% of their energy needs three meals consumed at 8 a.m., 1 p.m., and 8 p.m. (3007 ± 444.7 kcal/day, carbohydrates 54.7 ± 2.2%, fat 23.9 ± 3.5%, protein 21.4 ± 1.8).	In TRF: ↓ HDL-C (45.11 ± 5.89 to 58.06 ± 6.11 mg/dl) (p=0.014) ↓TG (54.11 ± 15.12 to 115.23 ± 11.77 mg/dl) (p=0.0052). NS changes in TC and LDL-C.	In TRF: ↓Glucose (96.64 ± 85.92 to 85.92± 7.13 mg/dl) (p=0.0011)	NM
Gnanou et al (2015)^Citation53	20 healthy men Age: 19–23 years.	Ramadan fasting	NM	↓ Blood glucose (p< 0.01)	NM
Varady et al (2013)^Citation35	32 normal-weight and overweight (22 Females- 8 Males): - ADF, n= 15 -CG, n=15 Age: 35 to 65 years BMI between 20 and 29.9 kg/m^2	For 12 weeks →ADF group alternated between fasting days (25% of kcal needs as determined by Mifflin equation; consumed between 12 pm and 2 pm) and ad libitum feeding days.	In ADF group: ↓Triacylglycerol (20 ± 8%, P < 0.05) ↑ LDL particle size (4 ± 1 Å, P < 0.01) NC in LDL-C, HDL-C	NM	NM
Bhutani et al (2013)^Citation32	83 obese (80 Females - 3 Males) -E-ADF, n=18 -ADF, n=25 -Exercise, n=24 -CG, n=16 Age: 25 to 65 years BMI: 30 to 39.9 kg/m^2	For 12 weeks →ADF and E-ADF groups alternated between fasting days (25% of kcal needs as determined by Mifflin equation; consumed between 12 pm and 2 pm) and ad libitum feeding days.	↓ TC (p =0.053). NS change in TG, HDL-C, LDL-C.	NS change in blood glucose	NC in C-reactive protein.
Eshghinia & Mohammadzadeh (2013)^Citation33	15 overweight and obese women. Age: 33.46 ± 5.9 years. BMI: 33.16 ± 5.02 kg/m^2.	For 6 weeks, On 3 weekly fasting days; Saturday, Monday, and Thursday (25%– 30% of energy needs) On 4 feeding days (1700–1800 kcal/d)	NS changes	NM	NM
Teng et al (2013)^Citation25	56 Men: - FCR, n=28 - CG, n=28. Age: 50 to 70 years. BMI: 23 to 29.9 kg/m^2.	For 12 weeks: → FCR: 300–500 kcal/d ↓ in caloric intake (For 2 non-consecutive days per week). →CG: NC in energy needs	A significant interaction effect in →TC (p<0.001) →LDL-C (p<0.05) → (TC)/HDL (P<0.05) NS effect in HDL and TG	NS change	NM
Klempel et al (2013)^Citation39	32 obese women: -ADF-HF, n=17-ADF-LF, n=18 Age: 25–65 years. BMI between 30 and 39.9 kg/m.^Citation2	For 8 weeks Alternated between fasting days (25% of kcal needs as determined by Mifflin equation; consumed between 12 pm and 2 pm) and ad libitum feeding days. The two diets: →ADF–HF (45% fat, 40% carbohydrate and 15% protein), →ADF–LF (25% fat, 60% carbohydrate and 15% protein).	↓ TC: 13 ± 2 and 16 ± 2% (P<0.0001) in the ADF–HF and ADF–LF. ↓ LDL-C: 18 ± 5 and 25 ± 3% (P<0.0001) in the ADF–HF and ADF–LF. ↓ TG: 14 ± 5 and 14 ± 4% (P<0.001) in the ADF–HF and ADF–LF. NC in HDL-C in either group.	NM	NM
Mirzaei et al (2012)^Citation58	14 male collegiate wrestlers (Age: 20.12±2.5 years).	Ramadan fasting	↓TC (P=0.011) ↓ LDL-C (P=0.001). ↑ HDL-C (P=0.045).	↓ Blood glucose (p=0.001).	NM
Shehab et al (2012)^Citation75	65 subjects -42 Males (BMI: 28.1±4.4 kg/m^2) - 18 Females (BMI: 27.2 ±5.5 kg/m^2). Age: 38.7±10.5 years	Ramadan fasting	↑HDL-C (P<0.001) ↓LDL-C (P< 0.001) NS change in TC and TG	NM	NM
Nematy et al (2012)^Citation74	Volunteers including - 38 Males (Age: 29–70 years) - 44 Females (Age: 54.0 ± 10 years)	Ramadan fasting	↓TC(P = 0.02) ↓TG (P <0.001) ↓VLDL-C (P <0.001) ↓ LDL-C (P <0.001) ↓TC/HDL (P <0.001) ↓LDL/HDL ratio (P <0.001) ↑HDL-C (P <0.001)	NS modification.	NM
Varady et al (2011)^Citation40	59 overweight and obese (50 Females- 9 Males): ADF, n=13 CR, n=12 Exercise, n=12 Control, n=12 Age: 35 to 65 years BMI: 25 to 39.9 kg/m^2	For 12 weeks: ADF and E-ADF groups alternated between fasting days (25% of kcal needs as determined by Mifflin equation; consumed between 12 pm and 2 pm) and ad libitum feeding days.	In ADF: NC in TC and HDL-C ↓LDL-C (P < 0.05) (10 ± 4%) ↓TG (P < 0.05) (17 ± 5%)	NM	NM
Varady et al (2009)^Citation34	60 obese (12 Females, 4 Males) Age: 35–65 years. BMI: 30 to 39.9 kg/m^2.	For 8 weeks: Alteration between fasting days (25% of kcal needs as determined by Mifflin equation; consumed between 12 pm and 2 pm) and ad libitum feeding days.	↓TC −21 ± 4% (P < 0.01) ↓LDL-C −25 ± 10% (P< 0.01) ↓Triacylglycerol −32 ± 6% (P< 0.01) NC in HDL-C	NM	NM
Chaouachi et al (2008)^Citation64	15 male elite judo athletes Age 18 ± 1 years	Ramadan fasting	↓TC (3.34 ± 0.26 to 3.72 ± 0.31 mmol • l –1) (P< 0.05) ↑HDL-C (1.30 ± 0.31 to 1.42 ± 0.28 mmol • l –1) (P < 0.01) NC in LDL-C and TG.	NC	↓ Protein from 77.1± 4.4 to 70.1 ± 4.3 g.l-1 (P < 0.01)
Ziaee et al (2006)^Citation81	81 healthy subjects (41 Males - 40 Females). Age: 20–35 years BMI: 21.2±4.5 kg/m^2	Ramadan fasting	↓HDL-C (P=0.001) ↑ LDL-C (P=0.045) NS change in TC, TG and VLDL.	↓ Glucose (p=0.000)	NM
Bouhlel et al (2006)^Citation67	9 trained men Age: 19±2 years BMI: 25.1±4.1 kg/m^2	Ramadan fasting	NM	NC	↑ Hemoglobin (P < 0.01)
Heilbronn et al (2005)^Citation82	16 healthy (8 Males- 8 Females) Age: 20 and 55 years BMI: 20.0 to 30.0 kg/m^2	ADF: fasting every other day for 22 days	NM	For females: ↓ Glucose (p= 0.01) NC in insulin response For males NC in glucose ↓Insulin response (p= 0.03).	NM
Fakhrzadeh et al (2003)^Citation73	91 subjects: -50 Males(Age: 19.9±1.8 years and BMI: 21.8 ± 2.6 kg/m^2) -41 Females(Age: 21.9±3.9 years and BMI: 24.0 ± 4.5kg/m^2)	Ramadan fasting	↓TC (P< 0.001) ↓ TG (P<0.001 for men, P < 0.02 for woman) ↓LDL-C (P < 0.001) ↑HDL-C (P < 0.001)	↓Glucose in both men (P<0.0001) and women (P<0.0001).	NM
Larijani et al (2003)^Citation83	67 male, 48 female adults Age: 15 to 45 years	Ramadan fasting	NM	↓Glucose (88.4 ± 9.0 mg/dl to 62.9 ± 7.7 mg/dl) (p < 0.001).	NM
Beltaifa et al (2002)^Citation76	26 athletes and 32 sedentary individuals	Ramadan fasting	NS modifications	NC	No significant change
Adlouni et al (1997)^Citation72	32 healthy men (Age: 25–50 years)	Ramadan fasting	↓TC: −7.9% (P< 0.001), ↓TG: −30% (P< 0.001) ↓LDL-C: −11.7% (P< 0.001) ↑HDL-C: −14.3%(P< 0.001).	↓ Blood glucose: 5.1 to 4.38 mmol/L (P < 0.001)	NM

Abbreviations: ADCR, Alternate Day Caloric Restriction ADF, Alternate Day Fasting; ADF-HF, Alternate Day Fasting with High Fat ADF-LF, Alternate Day Fasting with Low Fat; BMI, Body Mass Index; CR, Caloric Restriction; CCR, Continuous Caloric Restriction; E-ADF, Exercise With Alternate Day Fasting; EX, Exercise; FCR, Fasting Caloric Restriction; FG, Fasting Group; HDL-C, High Density Lipoprotein; ICR, Intermittent Caloric Restriction; LDL-C, Low Density Lipoprotein; n, number; NC, No Change; ND, Normal Diet; NFG, Non Fasting Group; NM, Not Mentioned; NS, Non Significant; TC, Total Cholesterol; TG, Triglycerides; TRF, Time Restricted Feeding.

Table 7 Effects of Fasting on Endurance Performances in Endurance Trained Athletes

Author	Participants	Study Design	Main Findings
Png et al (2014)^Citation88	12 active male runners Age: 27.9 ± 7.2 years	60 min of continuous run during the Ramadan month after ingesting → Low glycemic index → Normal mixed carbohydrate food as the sahur meal (post 12 hrs).	NS variations in metabolic and physiological measures. ↓Distance ran was in low glycemic index versus control meal trial
Brisswalter et al (2011)^Citation8	18 well trained males, middle-distance runners -Ramadan fasting, n=9 - CG, n=9 Age: 23.6 ± 2.9 years	→The maximal running test →Maximal voluntary contraction of knee extensor →2 rectangular submaximal exercises on treadmill for 6 mins →Running performance test (5000 m) (Before and at the last week of Ramadan)	NC in running efficiency or MAP.
Asl (2011)^Citation46	15 male endurance runners Age: 22.5 ± 1.14 years	In the first week and in the middle of Ramadan The aerobic power was measured by using30 mins running in stationary bike.	Small significant effect (P< 0.05)
Aziz et al (2010)^Citation89	10 moderately men trained runners Age: 27.3±7.2 years	Comparing the subjects (60 min runs on a treadmill) during the Ramadan month in the fasted state and non-fasted conditions. The 60 min continuous endurance running: 30 min preloading run at 65% maximum oxygen consumption intensity speed + 30 min where subjects adjusted their speeds	↑in the second 30 min in the control compared to Ramadan condition (5649±715 versus 5448±847 m, P=0.023). ↓ Blood glucose (4.5±0.3 versus 4.9±0.4 mmol/l, p=0.003) at the start of exercise in the Ramadan condition. NS changes in HR, blood lactate and RPE between the two conditions.
Chennaoui et al (2009)^Citation63	8 male middle-distance athletes Age: 25.0 ± 1.3 years	The MAV test: 5 days before Ramadan and on days 7 and 21 of Ramadan.	↓MAV values at days 7 and 21 (p < 0.05)
Loon et al (2004)^Citation90	8 male cyclists Age: 22.8 ± 0.8 years	Following an overnight fast, subjects were studied at rest, during 120 min of moderate intensity exercise (60% maximal oxygen uptake) and 120 min of post-exercise recovery.	↑Free fatty acid oxidation rates increased during exercise. ↓Use of other fat sources and muscle glycogen with the duration of exercise (P<0.001) ↑Plasma glucose production and utilization (P < 0.001).
Mehdioui, et al (1996)^Citation86	10 male distance runners	The maximal oxygen intake was measured in the beginning and the end of Ramadan	NC in maximal oxygen intake, ↑Endurance effort

Abbreviations: HR, Heart Rate; MAP, Maximal Aerobic Power; MAV, Maximal Aerobic Velocity; n, number, NC, No Change; NS, Non-Significant; RPE, Rating Perceived Exertion.

Table 8 Effects of Fasting on Physical Performances in Untrained Subjects and Non-Endurance Athletes

Author	Participants	Study Design	Main Findings
Hammouda et al (2014)^Citation54	12 males, professional soccer players Age 17.52 ± 0.2 years	The Yo-Yo test level 1(07:00 h and 17:00 h): one week before Ramadan, and in the second and fourth week.	↓Total distance just in the evening (P<0.05).
Lotfi et al (2010)^Citation62	9 athletes Age: 23 ± 3 years	Running 1000m test took place 3 times: before and in the first and fourth weeks of Ramadan.	NS modifications in physical performance (1000m running). ↓ RRT(p<0.001) ↓ TRT (p<0.0001)
Chaouachi et al (2009)^Citation8	15 healthy male elite judo athletes Age: 18 ± 1 years	A multistage fitness test was applied in the beginning and the end of Ramadan	NC of multistage shuttle-run score
Meckel et al (2008)^Citation11	19 male soccer players Age: 14–16 years	The endurance test “3,000 m run” the week before and during the last week of the Ramadan.	↓Aerobic capacity: 3,000 m run time: 812.8 ± 73.3s versus 819.9 ± 73.4s (P < 0.001)
Kirkendall et al (2008)^Citation10	85 soccer male players -2 teams for each morning and afternoon testing (fasting group and non-fasting group) Age: 18 years	20-m multistage shuttle run test took place 3 weeks: before and in the second and fourth weeks of Ramadan.	↑Running distance in the 4^thweek of Ramadan (P<0.05) and Post Ramadan (P<0.001) No time day effect.
Fouad (2008)^Citation91	30 male soccer players Age: 15 to 17 years	To measure the aerobic exercise performance a Leger test was applied in the beginning and the end of Ramadan	NC of Leger-test score or endurance at 85% of maximal oxygen intake during Ramadan
Karli et al (2007)^Citation9	16 male soccer players (Age: 17.4 ± 1.2 years)	20- multistage shuttle run test took place 3 times: before, in the beginning and in the end of Ramadan.	During Ramadan: ↑RPE (P<0.05). End of Ramadan: ↓Blood lactate (p<0.05) ↓HR responses (p<0.05) ↑Peak running performance (p<0.05) ↑running velocity at anaerobic threshold (p<0.05)
Sweileh (1992)^Citation92	Sedentary subjects	The maximal oxygen uptake measured in the beginning and the end of Ramadan	The maximal oxygen uptake: ↓ in the first week of Ramadan ↑last week of Ramadan

Abbreviations: HR, Heart Rate; NC, No Change; NS, Non-significant; RPE, Rating Perceived Exertion; RRT, Recognition Reaction Time; TRT, Total Reaction Time.

Figure 1 Exercise in fasted compared to fed states. Aerobic exercise performed in the fasted state induces higher fat oxidation than exercise performed in the fed state.

Abbreviations: NEFA, non-esterified fatty acids; ATGL, adipose triglyceride lipase; HSL, hormone-sensitive lipase; CD36, fatty acid translocase; CPT-1, carnitine palmitoyltransferase-1; UCP-3, uncoupling protein 3; AMPK, AMP-activated protein kinase; SIRT1, sirtuin-1.

Table 9 Effect of Endurance Training on Fast State on Endurance Performance

Authors	Participants	Study Design	Main Findings
Bouguerra et al (2017)^Citation11	24 male middle- and long-distance runners Afternoon group, n=8 (14,00 to 16.00 h) Morning group, n=8(09,00 to 11.00 h) Evening group, n=8 (22,00 to 24.00 h) Age, 28.5 ± 10.6 years	Maximal aerobic velocity, time to exhaustion, performance in running 3000-m (Before, at middle, and after Ramadan fasting training)	↑MAV and maximal oxygen uptake (P< 0.01) in the afternoon and morning groups compared to the evening group. Before and after Ramadan ↑ Time of 3000-m running exercise (P < 0.001) ↓Time to (p <0.001) in the evening and Morning groups compared to the afternoon groups
Van Proeyen et al (2011)^Citation100	20 healthy males -Training group in fasted state “overnight fasting” (n=10) -Training group in fed state (n=10, carbohydrates before (∼160 g) and during (1 g.kg body wt−^Citation1·h−^Citation1) the training sessions) Age, 18–25 years	6 weeks of endurance training program (1–1.5 h cycling at ∼70% of maximal oxygen uptake 4 days/wk)	↑ Maximal oxygen uptake (+9%) (P < 0.01) ↑Performance in a 60-min simulated time examination (+8%) in both groups (P < 0.01). In fasting, intramyocellular lipid breakdown was enhanced in type I fibers (P < 0.05), tended to be ↑ in type IIa fibers (P=0.07).
Stannard et al (2010)^Citation113	8 females and 6 males untrained, -Training groups, overnight-fasted -Training groups, acutely fed state Age, 26.6 ± 5.8 years	For4 weeks of 5 days per week endurance cycle ergometer training	In fast, ↑Maximal oxygen uptake and resting muscle glycogen concentration (P=0.014) than fed (P=0.047) NS gender interaction.

Abbreviations: MAV, Maximal Aerobic Velocity; n, number; NS, Non-Significant.

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