IndoJPMR Vol. 11 - 2nd Edition - december 2022 ORIGINAL ARTICLE Fatigue. Sleepiness. Anxiety-Depression Score. Calories and BDNF Serum Level. Quality of Life Alteration During Holy Ramadhan Month Deta Tanuwidjadja1. Irma Ruslina Defi1. Jennie Jennie2 Department of Physical Medicine and Rehabilitation. Faculty of Medicine. Padjadjaran University. Dr. Hasan Sadikin General Hospital. Bandung. Indonesia Faculty of Medicine. Maranatha Christian University. Bandung. Indonesia ABSTRACT Introduction: Ramadhan fasting increases mental and physical health. The study aims to evaluate the effect of Ramadhan fasting on fatigue, sleepiness, depression and anxiety mood, quality of life (QoL), calories consumed and Brain-derived neurotrophic factor (BDNF) serum level. Methods: Twenty participants are included in the fasting group (FG), and nineteen participants are included in the non-fasting group (NFG). Fatigue severity scales (FSS), fatigue VAS. Epworth sleepiness scale (ESS), hospital depression and anxiety score (HADS). Beck depression inventory (BDI)-II. Short form 12 (SF-. , and BDNF in both groups were assessed at five-time points: one week before Ramadhan (T. , in the middle of Ramadhan (T. , the last days of Ramadhan (T. , one week after Ramadhan fasting (T. two weeks after Ramadhan (T. Results: We found no significant differences across the time points between FG and NFG groups in all variables . >0. There is a significant correlation between fatigue VAS with BDNF serum levels . > r tabl. SF-12 PCS . >r tabl. with BDNF. SF-12 MCS . >r tabl. There is no correlation between fatigue, depression and anxiety intensity, sleepiness. QoL. BDI-II, and BDNF serum levels with calories consumed. BDI-II, and BDNF of fasting group in Ramadhan . < r tabl. Conclusions: Ramadhan fasting has positive effects on fatigue and mood. Ramadhan fasting does not have a significant effect on sleepiness, physical exercise, and calories consumed. Fatigue VAS and SF-12 PCS can replace the serum BDNF examination Keywords: BDNF, depression, fatigue, quality of life, ramadhan fasting | IndoJPMR Vol. 11 - 2nd Edition - December 2022 ABSTRAK Pendahuluan: Puasa Ramadhan meningkatkan kesehatan mental dan fisik. Penelitian ini bertujuan untuk mengevaluasi pengaruh puasa Ramadhan terhadap kelelahan, rasa kantuk, mood depresi dan kecemasan, kualitas hidup, dan tingkat serum Brain-derived neurotrophic factor (BDNF) Metode: Dua puluh peserta termasuk dalam kelompok puasa dan sembilan belas peserta termasuk dalam kelompok tidak puasa. Kedua kelompok dinilai Fatigue severity scales (FSS), fatigue VAS. Epworth sleepiness scale (ESS), hospital depression and anxiety score (HADS). Beck depression inventory (BDI)II. Short form 12 (SF-. , dan BDNF pada lima waktu: satu minggu sebelum Ramadhan (T. , di tengah Ramadhan (T. , hari terakhir Ramadhan (T. , satu minggu setelah puasa Ramadhan (T. , dan dua minggu setelah Ramadhan (T. Hasil: Tidak ditemukan perbedaan yang signifikan antara kelompok puasa dan tidak puasa di semua variabel . >0,. Ada hubungan yang signifikan antara fatigue VAS dengan kadar serum BDNF . > r tabe. SF-12 PCS . >r tabe. dengan BDNF. SF-12 MCS . >r tabe. Tidak ada hubungan antara fatigue, depresi dan kecemasan, rasa kantuk, kualitas hidup. BDI-II, dan kadar BDNF serum dengan kalori. BDi, dan BDNF pada kelompok puasa . < r tabe. Kesimpulan: Puasa Ramadhan mempunyai efek positif pada fatigue dan mood. Puasa Ramadhan tidak mempunyai efek yag signifikan terhadap rasa kantuk, latihan fisik, dan kalori yang dikonsumsi. Fatigue VAS dan SF-12 PCS dapat digunakan untuk mengganti serum BDNF. Kata Kunci: BDNF, depresi, fatigue, kualitas hidup, puasa ramadhan Correspondent: Irma Ruslina Defi. MD. PhD Department of Physical Medicine and Rehabilitation. Faculty of Medicine. Padjadjaran University. Hasan Sadikin General Hospital. Bandung. Indonesia Email: irma. ruslina@unpad. INTRODUCTION According to Sural Al-Baqarah: 183, fasting is an act conducted by Muslims to achieve righteousness . 1 Fasting during the month of Ramadhan is one of the five main pillars of Islam. 2 Surah Al-Baqarah:187 mentions all adult Muslims who are not acutely sick, pregnant, menstruating, or breastfeeding must refrain from eating, drinking, smoking, violence, anger, and sex from dawn . to sunset . for 29 to 30 days of the fasting 1 The duration of Ramadhan fasting depends on geographic location and seasonAi ranging between 10 to 18 hours per day. 3 The length of Ramadhan fasting in Indonesia is about 14 hours, from 4 am to 6 pm local time. Ramadhan fasting has been known to have a health improvement effect. 4 Ramadhan fasting improves spiritual as it can also greatly affect physical health such as blood pressure, lipid profile, oxidative stress and antioxidant status. A study by Amin et al. found various positive IndoJPMR Vol. 11 - 2nd Edition - december 2022 impacts of Ramadhan fasting on mental health, including depression, anxiety, and stress. However, the changes in drinking and eating habits, mental and physical activities can cause several problems such as fatigue and increased sleepiness for those who undergo fasting. A study from Alessio et al, patients with major depression appeared to have lower Brainderived neurotrophic factor (BDNF) levels in whole blood, serum, or plasma. 9 Therefore, based on the known positive effects of fasting in improving mood states, we are interested in evaluating whether the serum BDNF can assess the depression value during this holy month of Based on these considerations, this study aims to evaluate the effect of Ramadhan fasting on fatigue, sleepiness, mood, quality of life, and BDNF serum levels and its correlation to further explore the benefits of fasting. METHODS Prior to the study, ethical clearance was obtained from the Profession and Research Ethics Committee of Medical Committee Faculty of Medicine. Padjadjaran University . thical clearance number: 251/UN6. KEP/ EC/2. As required, procedures and ethical aspects of current research have been conducted in full accordance with the World Medical Association Declaration of Helsinki. All participants agreed to participate based on informed consent. All participants completed 30 days of fasting starting from 27 May 2017 to 24 June 2017. Thirty-nine healthy men are included in this study and divided into two groups. Twenty healthy men performed fasting during Ramadhan . asting group. FG) and nineteen healthy men served as a control group by not fasting . on-fasting group. NFG). The inclusion criteria for the fasting group are: . be healthy, . be older than 18 years of age, . intend to fast the 86 whole month of Ramadan, . have fasted during Ramadhan at least once before, . can understand a command and communicate in Bahasa Indonesia. Both groups were then measured at five-time The first measurement (T. was taken one week before the beginning of Ramadhan, the second measurement was in the middle of Ramadhan (T2: two weeks after T. , the third measurement was during the last days of Ramadhan (T. , the fourth measurement was one week after the end of Ramadhan (T. , and the last measurement was two weeks after the end of Ramadhan (T. Fatigue is measured by the fatigue severity scale (FSS) and fatigue visual analog scale (VAS). FSS is a questionnaire consisting of 9 items that evaluate the fatigue level with a linear score of 1 . trongly disagre. to 7 . trongly agre. This questionnaire can evaluate the impact of fatigue and VAS with a score from 0 . o fatigu. to 10 . he worst imaginable fatigu. Mood intensity in this study is measured using the Hospital Depression and Anxiety Score (HADS) and BeckAos Depression Inventory (BDI)AeII questionnaire. HADS consists of fourteen items divided into two domains: seven | IndoJPMR Vol. 11 - 2nd Edition - December 2022 items of anxiety scales and another seven items to assess depression level. The score of each parameter is between 0 to 21. If the score is 8 or more than 8, it indicates the symptoms of anxiety or depression. 11 BDI-II consists of 21 items to measure the severity of depression and scored between 0 to 63. The higher the BDI-II score is, the more severe the depression. Day sleepiness is measured using Epworth Sleepiness Scale (ESS) questionnaires and Sleepiness VAS. ESS consists of 8 items, and each item is rated between 0 to 3. ESS score is the sum of 8 items and scored between 0 to High ESS values indicate a high tendency of average daily life sleepiness in individuals. Short Form 12 questionnaire (SF-. is used to measure both mental and physical 14 There are 12 items in the SF-12 questionnaire comprising 8 domains: physical functioning, role limitations due to physical health problems, bodily pain, general health, vitality, social functioning, role limitations due to emotional problems, and mental health. higher score indicates better quality of life. Brain-derived neurotrophic factor (BDNF) serum samples are collected during each of the five-time points in both groups. 5 mL of blood was collected from the subjectsAo serum blood by laboratory personnel. BDNF serum levels are then analyzed using a quantitative sandwich enzyme immunoassay technique by Quantikine ELISA Human CXCL-8/IL-8 HS. 24 hours. This method is also used to screen individual nutritional intake. The advantage of this method is it requires only minimal tools and can be done at any time. 16 All subjects were instructed to record their daily dietary intake and calculate it using household measurements . poon, slice, glass, plate, and bow. Food recall results represent the average of food calories consumed in breakfast, lunch, and The recall is conducted twice a week for each measurement (T1 - T. However, because the FG was fasting during T1-T3, they only conducted the Food Recall at dawn and dinner and calculated the average between the two. Numerical data analysis is tested using the unpaired T-test if the data are normally distributed and the alternative Mann Whitney test if the data are not normally distributed, namely Age. A paired T-test is used to compare T1 and T2. T1 and T3. T1 and T4, and T1 and T5 in FG and NFG. Pearson and SpearmanAos analysis performed a correlation between fatigue, sleepiness, depression intensity, and QoL with BDNF. Statistical analysis is performed using SPSS version 22 (IBM. New York USA). Significant is set at p < 0. RESULTS 24-hour Food Recall is a method that focuses on the subjectAos ability to recall all the food and The mean (A SD) age of the fasting group (FG) patients is 29. 65 A 4,209 years old. The FG is consisted of 20 people who are all men . %) and of mongoloid race . %). The mean (A SD) age of the patients in the non-fasting group (NFG) is 25. 26 A 5,162 years old. The NFG consists of 19 people who are all men . %) drinks an individual consumed during the last and of mongoloid race . %) (Table . IndoJPMR Vol. 11 - 2nd Edition - december 2022 Table 1. Demographic characteristics in fasting group and non-fasting group Group Variable Age Mean A Std Median Range . in-ma. Fasting Group (FG) N=20 Non-Fasting Group (NFG) N=19 65 A 4. 26 A 5. Gender Men 20. Women 0. Race Mongoloid 20. *p<0. 05, **p<0. We found no significant differences across the time points between FG and NFG groups in all variables . > 0. (Table . However, in Table 3, we found a significant difference in FG between T1 and T3 BDNF serum levels . 93 A 5. 135 to 6. 82 A 4. 946, p < 0. and T1 with T2 Fatigue VAS . 86 A 2. 148 to 5. A 2. 077, p<0. The significant differences of HADS-Depression in FG can be seen by comparing T1 with T3 . 45 A 2. 139 to 1. A 1. 804, p<0. T1 with T4 . 45 A 2. 139 to 80 A 1. 989, p<0. , and T1 with T5 . A 2. 139 to 1. 65 A 1. 980, p<0. There are significant differences in HADS-Anxiety score in FG when comparing T1 with T3 . 226 to 2. 90 A 2. 337, p<0. T1 with T4 . 75 A 3. 226 to 2. 95 A 3. 605, p<0. , and T1 with T5 . 75 A 3. 226 to 2. 50 A 3. 204, p<0. and significant BDI-II when comparing T1 with T3 . 80 A 4. 099 to 3. 05 A 3. 531, p<0. with T4 . 80 A 4. 099 to 2. 85 A 4. 557, p<0. and T1 with T5 . 80 A 4. 099 to 3. 05 A 4. p<0. There is a significant difference of calories in FG between T1 with T4 . A 438. 875 to 1638. 20 A 419. 021, p<0. and T1 with T5 . 10 A 438. 875 to 1694. 892, p<0. There are no significant differences between the time points in most of the variables in NFG . > 0. , except the comparison of T1 with T4 in HADS-Anxiety . 75 A 3. 226 to 2. 605 p<0. and T1 with T3 . 84 A 7. 21 A 10. 147, p<0. also T1 with T4 . A 7. 37 A 10. 838, p<0. in FSS (Table . 10 A 438. 53 A 263. NFG . 83 A 3. NFG . FG . 93 A 5. 56 A 10. NFG . FG . 91 A 7. FG . 00 A 268. 55 A 343. 70 A 4. 67 A 4. 52 A 13. 42 A 7. 96 A 6. 63 A 3. 11 A 2. 27 A 1. 42 A 5. 20 A 5. 89 A 12. 30 A 4. 95 A 3. 50 A 1. 37 A 4. 10 A 2. 78 A 2. 72 A 2. 37 A 9. 30 A 8. Mean A SD 74 A 327. 00 A 385. 46 A 4. 82 A 4. 14 A 11. 36 A 7. 88 A 6. 62 A 3. 28 A 2. 92 A 1. 26 A 5. 30 A 4. 89 A 9. 05 A 3. 21 A 3. 90 A 1. 68 A 4. 90 A 2. 22 A 2. 78 A 1. 21 A 10. 30 A 8. Mean A SD 11 A 397. 20 A 419. 94 A 4. 67 A 4. 85 A 8. 26 A 8. 69 A 7. 81 A 7. 52 A 2. 37 A 1. 90 A 4. 35 A 4. 79 A 10. 85 A 4. 37 A 5. 80 A 1. 68 A 3. 95 A 3. 51 A 2. 36 A 1. 37 A 10. 45 A 9. Mean A SD 05 A 296. 85 A 431. 67 A 3. 43 A 3. 98 A 8. 76 A 7. 09 A 6. 60 A 5. 91 A 2. 23 A 1. 58 A 6. 37 A 6. 63 A 10. 05 A 4. 16 A 4. 65 A 1. 79 A 3. 50 A 3. 08 A 1. 52 A 2. 27 A 9. 20 A 7. Mean A SD VAS = Visual Analogue Scale. Hospital Depression and Anxiety Score (HADS). SF-12 PCS = Short Form 12 Physical Component Score. MCS = Mental Component Score. BDNF = Brain-derived neurotrophic factor. *p<0. Calories BDNF SF-12 MCS 88 A 6. NFG . 06 A 1. NFG . 67 A 6. 40 A 1. FG . Sleepiness VAS FG . 63 A 4. NFG . SF-12 PCS 25 A 3. 79 A 8. NFG . FG . 80 A 4. 26 A 2. NFG . FG . 45 A 2. FG . Epworth Sleepiness Score (ESS) Beck Depressing Inventory II HADS Depression 58 A 3. NFG . 44 A 1. NFG . 75 A 3. 86 A 2. FG . Fatigue VAS FG . 84 A 7. NFG . HADS-Anxiety 00 A 12. Mean A SD FG . Group Fatigue Severity Scale (FSS) Variable Table 2. Fatigue. Mood and health-related QoL and significant difference between fasting group and non-fasting group | IndoJPMR Vol. 11 - 2nd Edition - December 2022 IndoJPMR Vol. 11 - 2nd Edition - december 2022 Table 3. Comparison between Time Points in fasting group and non-fasting group Variable Group Fatigue Severity Scale (FFS) FG . NFG . Fatigue (VAS) FG . NFG . HADS-Anxiety FG . NFG . HADS-Depression FG . NFG . Beck Depressing Inventory II FG . NFG . Epworth Sleepiness Score FG . NFG . Sleepiness VAS FG . NFG . SF-12 PCS FG . NFG . SF-12 MCS FG . NFG . BDNF FG . NFG . Calories FG . NFG . Pa = T1vsT2 significant difference. Pb = T1vsT3 significant difference. Pc = T1vsT4 significant difference. Pd = T1vsT5 significant difference. VAS = Visual Analogue Scale. Hospital Depression and Anxiety Score (HADS). SF-12 PCS = Short Form 12 Physical Component Score. MCS = Mental Component Score. BDNF = Brain-derived neurotrophic factor. *p<0. Table 4. Correlation between fatigue, mood, sleepiness, and quality of life with BDI-II. BDNF serum levels, and calories in the fasting group BDI-II FFS Fatigue VAS HADS-Anxiety HADS-Depression SF-12 PCS SF-12 MCS ESS Sleepiness VAS BDI-II BDNF BDNF Calories BDI-II = Beck depression inventory II. VAS = Visual Analogue Scale. HADS = hospital depression and anxiety score. ESS = Epworth sleepiness scale. SF-12 PCS = Short Form 12 Physical Component Score. MCS = Mental Component Score. BDNF = Brain-derived neurotrophic factor. *p<0. | IndoJPMR Vol. 11 - 2nd Edition - December 2022 Table 4 shows the results of the Spearman correlation test statistical analysis between the fatigue, mood, sleepiness, and quality of life with depression parameters BDI-II and BDNF. Thus, we found a significant correlation between fatigue VAS with BDNF serum levels with moderate correlation strength . > r tabl. There is a moderate correlation between SF-12 PCS . >r tabl. and BDNF, but not with SF-12 MCS . r tabl. has a moderate correlation with BDi but not with SF-12 PCS .