J Fam Med Dis Prev ISSN: 2469-5793

• Abstract
• Keywords
• Introduction
• Lifestyle Interventions in the Prevention of Obesity
• Eating Behavior and Weight Management
• Eating Together
• Childhood Obesity
• Diet
• Exercise
• Obesity and Sleeping Patterns
• Implications for Treatment
• Conclusion
• Table 1
• References

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Journal of Family Medicine and Disease Prevention

¹Community and Family Medicine Department, King Abdulaziz University, Saudi Arabia
²Bioethics Department, International Medical Center, Saudi Arabia

Abstract

The prevalence of obesity and, consequently, obesity-related disorders is increasing globally, imposing a burden on health care and costs. Lifestyle interventions are the mainstay of treatment owing to the risks associated with surgery and medications. Although Islam advocates a healthy lifestyle and dieting, Muslim countries are also plagued by a rise in the prevalence of obesity and its associated disorders due to substitution of the traditional diet for a Western diet, which is rich in fats and free sugars. This review focuses on scientific based lifestyle recommendations for weight management that might be influenced by the Qur'an. We also describe evidence from contemporary research regarding the effectiveness of lifestyle interventions that are also encouraged in Islam.

Keywords

Behavior, Diet, Exercise, Fasting, Islam, Obesity

Introduction

Research has demonstrated that overweight and obese people have an increased risk of developing the following conditions: coronary artery disease, type 2 diabetes mellitus, dyslipidemia, cerebrovascular accident, cancers of the endometrium, breast and colon cancer, liver and gall bladder disease, osteoarthritis, sleep apnea, respiratory difficulties, as well as abnormal periods and infertility in women [1]. Unfortunately, over the last decade, Arab and gulf countries have witnessed an unprecedented increase in the incidence of heart disease and obesity-related diseases as well as an increase in the prevalence of obesity and overweight in both adults and children [2]. The prevalence of obesity among children and adolescents in Gulf nations range between 5-14% in males and from 3-18% in females. The rate varies from 2-55% among adult females and from 1-30% in adult males. An analysis of 46 Muslim countries demonstrated that the overall prevalence of obesity in these populations was 37.4%. Men and women were overweight in approximately 33.0% and 42.1% of the cases, respectively [3].

The increase in the prevalence of obesity and overweight in both adults and children in Arab and Gulf nations has been attributed to substitution of the traditional Arabic diet for a Western diet, which is rich in fats and free sugars [4]. This change in diet is associated with a concomitant increase in the prevalence of diet-related diseases, including congestive heart disease, diabetes, and cancers [4], which subsequently places a substantial health and economic burden on affected individuals and the society as a whole. The increasing wealth in Gulf Arab countries resulted in a sedentary life and less exercise.

In Saudi Arabia and other developing countries, there are limited pharmacological options for weight loss. Furthermore, bariatric treatment is costly and not within the reach of most individuals, and it has a few serious adverse effects. As a result, conservative treatment is the mainstay of any weight loss regime [5-7]. Several studies [8-10] have confirmed the role of exercise and diet on body weight; however, the role of religion on weight loss has received little attention, as evidenced by lack of epidemiological and randomized controlled trials that incorporate the religion of participants into the data analysis.

Reawakening the Muslim population to Islamic lifestyle recommendations to tackle this social and substantial health problem is main aim of this review. We also describe evidence from contemporary research regarding the effectiveness of lifestyle interventions that are also encouraged in Islam. Verses from the Qur'an and the teachings of Prophet Muhammad (peace be upon him [pbuh]) are used in this review to summarize the Islamic views of obesity and describe its similarity with current research. Verses from the Qur'an and the Hadith are used as sources of Islamic literature. Qur'anic citations are written as surah and verse number, separated by a colon (surah: verse), while Hadith citations are written as the cited book.

Lifestyle Interventions in the Prevention of Obesity

Over the last decade, exciting advances have occurred in all three modalities used to treat obesity: lifestyle intervention, pharmacotherapy, and bariatric surgery. Lifestyle and behavioral interventions have been reported in clinical trials [11,12] to produce and sustain weight loss, leading to favorable health outcomes, namely improvements in cardiovascular risk factors and the prevention and treatment of diabetes. Interestingly, the Islamic literature had emphasized the importance of behavioral practices, including the importance of dieting, approximately 15 centuries ago [13]. Although sustainable, lifestyle and behavioral interventions work only as long as patients are willing to do it. In addition, most conservative programs fail in the bariatric population [14].

Eating Behavior and Weight Management

Numerous factors within the food environment may trigger overfeeding. In Islam, Muslims are ordered by Allah Almighty to make balances in food and drink; overeating is believed to be an enemy of moral, healthy, and spiritual life. In one verse, Almighty Allah said: "And those who, when they spend, are neither extravagant nor niggardly, but hold a medium (way) between those (extremes).” (Surah Al-Furqan: 67). In another Qur'anic verse, Allah almighty advices humans not to be extravagant: "Eat and drink, but be not excessive. Indeed, He likes not those who commit excess." (Surah Al-A'raf: 31). "Eat of what Allah has provided for you, and follow not the footsteps of Shaitân (Satan). Surely he is to you an open enemy". (Surah Al-An'am: 141-142).

According to modern research [15,16], hyperphagia may contribute to obesity, thus raising the potential of common underlying mechanisms involved in the development and treatment of obesity in persons who increase their caloric intake. Although it was previously thought that obesity was primarily due to an energy-sparing metabolic defect, recent research [17] suggests that obese persons overeat and actually demonstrate increased, rather than decreased, energy use. Some authors showed that glucose administration increased the expression of brain-derived neurotrophic factor (BDNF) [18], which is known to have potentially anorexigenic activity [16]. Conversely, it was shown that food deprivation reduced its expression in the hypothalamus and dorsal vagal complex [19,20]. Moreover, clinical and experimental models showed that BDNF was associated with obesity that was mainly the result of overeating [21-25], and some contributing brain sites were identified [18,26]. This knowledge has been utilized in promoting behavioral strategies to control the amount of food consumed.

Previous research [27,28] also shows that intermittent fasting is beneficial in the treatment of obesity. Recent studies on experimental models show that fasting periods increase longevity, improve health and reduce disease, including cancers [29,30], neurological disorders [31], and disorders of the circadian rhythm in laboratory animals [32,33]. Weight loss regimens were initially based upon intermittent starving, contrary to restricting calories [34]. ]Intermittent fasting was reported to cause significant reductions in body weight in individuals with obesity [35], suggesting that it was clinically relevant in inducing weight loss.

The basic format in intermittent fasting involves alternating days of "normal" calorie consumption with days when calorie consumption is severely restricted. This can be done by fasting on an alternate-day basis or, according to recent research [36], using a 5:2 strategy where every week two days are selected as "fasting days" (men are allowed to consume up to 600 calories and women 500 calories per fasting). The Sunnah of Prophet David (pbuh) recommends fasting every other day. Fasting on Monday and Thursday, which is observed by some Muslims, is also part of the Sunnah. Islam encourages facultative fasting on Monday and Thursday every week, three days in the middle of the lunar month, on the ninth and tenth day of the month of Muharram, and six days in the month of Shawwal, which follows Ramadan (Sahih Muslim). This type of intermittent fasting has notably demonstrated good results and has been reported to be similarly or more effective than continuous modest calorie restriction with regard to weight loss, improved insulin sensitivity, and other health biomarkers [37,38].

Caloric restriction may be a better option to control weight. In fact, a 20-year longitudinal study [39] was conducted in rhesus monkeys with the aim of at determining whether caloric restriction without malnutrition delayed aging and extended lifespan in diverse species. The investigators concluded that adult-onset, moderate caloric restriction delayed the onset of age-associated diseases and prolonged life in a primate species. It was also thought that the advantages of caloric restriction could also be observed in humans since it was closely related to the rhesus monkey [39].

Muslims are instructed by Almighty Allah to fast during Ramadan. The Ramadan fast is similar to intermittent fasting in that it involves temporary food restriction. During this period, Muslims must abstain from eating, drinking, taking oral medications, having marital intercourse, and smoking from early dawn (Sohur) till sunset (Iftar). However, there is no restriction on food or fluid intake between sunset and dawn, although Muslims are instructed not to be gluttons. They are advised to have long prayers (Taraweeh) collectively in mosques. The main meal, Iftar, is taken at sunset and should start with dates and water, followed by Maghrib (Sunset) prayers. Sohur, the lighter meal, is taken before dawn and is mainly composed of complex carbohydrates and yogurt.

Findings from a prospective, observational trial that investigated the effect of Ramadan fasting on middle-aged subjects showed a significant reduction in body weight (mean weight of 66.6 ± 13 Kg before versus 65.2 ± 12.7 Kg after Ramadan; P < 0.0001) [40]. Similar findings were reported in a larger study [41] that investigated the effects of Ramadan intermittent fasting on body weight and composition and the effects of age and gender. The results showed significant reductions in weight and body mass index (BMI) (P < 0.001) in almost all subjects, with the largest weight loss and body fat reduction was observed in men ≤ 35 years (-2.2% [SE 2.2%]; P < 0.001). Waist and hip circumferences decreased in most subjects, except in women aged 36-70 years. In most subjects, fat mass decreased, ranging from 2.3% to 4.3% from baseline, except in women aged 36-70 years who did not show a significant change. Overall, the bottom line is for people to be disciplined regarding food choices and intake to maintain a healthy weight during Ramadan. Long-term studies are required to investigate the association between Ramadan fasting and weight control [42].

Eating Together

Islam emphasizes the concept of sharing meals. During Ramadan, Muslims get together to eat meals, either in public places such as mosques or in private such as in residences. While there is no strong scientific evidence, it is suggested that families who eat five or more meals together have children who are approximately 25% less likely to develop nutritional health issues than children who eat none or one meal with their families [43]. Furthermore, the authors found that shared family meals apparently prevented overweight, unhealthy eating, and disordered eating.

Childhood Obesity

Childhood obesity is an issue of concern in middle eastern countries. In Saudi Arabia, for example, data from a national survey indicated that 23.1% of children and adolescents were overweight and 9.3% were obese; severe obesity was documented in 2.0% of the sample [44]. Several risk factors were associated with childhood obesity, including poor feeding habits and lack of physical activity as a result of rapid modernization and urban residence, which has been observed in other Gulf States [45].

Islam encourages mothers to breastfeed their babies. In one verse of the Qur'an, it is stated: "The mothers shall give suck to their children for two whole years, (that is) for those (parents) who desire to complete the term of suckling)."(surah al-Baqarah: 233). In contemporary medicine, researchers have attempted to investigate the association between breastfeeding and obesity prevention in children; however, conflicting results have been published in this regard. Some authors advocate breastfeeding as a means to prevent childhood obesity [46,47]. Indeed, a meta-analysis demonstrated that breastfeeding was protective against childhood obesity [48] and recent research suggests that breastfeeding probably conferred a decreased risk owing to intestinal microbiota [49]. Other investigators [50] concluded that the duration and exclusivity of breastfeeding did not prevent overweight or obesity in children.

A number of strategies have been suggested to combat childhood obesity. These include active game involvement, limiting screen time and school intervention programs regarding healthy food choices [45,51].

Diet

Islam encourages dieting, as seen in several verses of the Holy Qur'an, which promote the consumption of pure and healthy food [13]. Part of the etiquette of eating is moderation in eating and not filling the stomach. According to the Islamic scriptures, "A man does not fill any vessel worse than his stomach. It is sufficient for the son of Adam to eat enough to keep him alive. But if he must do that, then one-third for his food, one-third for his drink and one-third for his air." (Narrated by al-Tirmidhi, 2380; Ibn Maajah, 3349; classed as saheeh by al-Albaani in Saheeh al-Tirmidhi, 1939). This keeps the body healthy and light, because eating one's fill makes the body heavy and leads to laziness in worship and work. One-third is defined as being one-third of that which would make you feel full. Muslims are also instructed to eat only meat that has been prepared following Islamic laws and to avoid eating pork. "He has only forbidden to you dead animals, blood, the flesh of swine, and that which has been dedicated to other than Allah. But whoever is forced [by necessity], neither desiring [it] nor transgressing [its limit], there is no sin upon him. Indeed, Allah is Forgiving and Merciful". (Surah al-Baqarah: 173).

Some fruits and plant extracts that have been used in traditional Arabic and Islamic medicine, such as Alchemilla vulgaris (lady's mantle), Cuminum cyminum L. (cumin), Mentha logifolia L. (sorting menthe) and Olea europaea L. (olive) have been shown to cause weight loss in modern research [52]. Besides being an important element in traditional Arabic and Islamic medicine, olive oil is one of the staples of Mediterranean diets. In one randomized controlled trial [53], it was found that the Mediterranean diet, when enriched with extra-virgin olive oil, decreased diabetes risk in persons with high cardiovascular risk. Furthermore, a low-carbohydrate Mediterranean diet causes a greater reduction of HbA1c levels, higher rate of diabetes remission, and delayed need for diabetes medication compared with a low-fat diet in patients with newly diagnosed type 2 diabetes [54]. In another report [55], it was shown that persons who consumed the Mediterranean diet had a significant decrease in body weight and BMI. A recent investigation [56] also found that the seeds and extracts of Nigella sativa (black seeds) had beneficial effects in persons with diabetes mellitus, insulin resistance syndrome, dyslipidemia, and cardiovascular diseases.

Dates are a staple food in the Arab world and are traditionally consumed by Muslims, especially during fasting periods. Although raw dates are rich in sugars as well as dietary fiber, enzymes, protein, fat, minerals, vitamins, phenolic acids, and carotenoids [57], a large proportion of date varieties are low in carbohydrates, refuting the belief that when consumed regularly, they have the potential to cause chronic diseases, similar to sweets [58].

Islam encourages the consumption of water. One Hadith says: "Zamzam water is what one intends to drink it for. When one drinks it to be healed, Allah heals him; when one drinks it to be full, Allah makes him full; and when one drinks it to quench his thirst, Allah quenches it. "(Ahmad and Ibn Majah). The Prophet (pbuh) is also quoted, "The most sublime of all earthly waters is that of Zamzam; therein one finds food for the hungry and medicine for the ill."(At-Tabarani).

In contemporary research [59], there is evidence that the consumption of ≥ 1500 mL of water causes a modest decrease in body weight and BMI in overweight persons. Furthermore, findings from one investigation [60] revealed that water intake in place of sugar-sweetened beverages or fruit juices was associated with lower long-term weight gain.

Islam also encourages the consumption of milk, as seen in this verse of the Qur'an: "And indeed, for you in grazing livestock is a lesson. We give you drink from what is in their bellies - between excretion and blood - pure milk, palatable to drinkers." (surah Al-Nahl: 66) While the Holy Qur'an does not indicate why milk is important in preventing obesity, data from current research [61] suggest a neutral effect of dairy intake on adiposity in early and middle childhood and a modest but protective effect during adolescence.

Exercise

The health and social benefits of exercise have been known for several decades. Exercise is mainly considered for its effects on energy expenditure for the prevention and treatment of both overweight and obesity. Several studies [62-64], including randomized controlled trials [11,65] have shown the benefits of exercise, either singly or in combination with other weight-loss modalities, in causing weight loss. Furthermore, there is evidence that brisk walking or regular exercise caused a slight decrease in body weight and body fat in postmenopausal women and moderate physical activity appeared to be as effective as aerobic exercise in improving and sustaining weight loss [66].

Muslims are encouraged to be physically active. Muslims can walk for any of the following worthy purposes: worshiping, working, seeking knowledge, exercising, participating in a race, and visiting. Walking for the purpose of worship is regarded as the worthiest in Islam, and it is believed that a Muslim's reward is increased depending on the number of steps taken to the mosque. In one Hadith, Abu Hurairah (radi Allahu anhu) reported that the Prophet (pbuh) said: "He who purifies himself (performs Wudhu) in his house and then walks to one of the houses of Allah (Masjid) for performing an obligatory Salat (prayer), one step of his will wipe out his sins and another step will elevate his rank (in Jannah)." (Sahih Muslim).

Prophet Muhammad (pbuh) ordered his companions to learn wrestling, riding horses, archery, swimming, running fast, and all types of arts of fighting. He usually had racing competitions with his wife Aisha (r.a).

Obesity and Sleeping Patterns

Late bedtime and night time snacking are associated with obesity. A recent report found that clock genotype is an important factor that affects eating patterns [67]. Similarly, Islamic scriptures recommend that Muslims should sleep early and wake up at dawn for worship, preferably to pray and meditate. Prophet Muhammad (pbuh) advised his followers to pray at night when people are asleep. The best time for facultative night prayers is the last third of the night (before dawn) when Almighty God approaches his servants with his mercy. Although there might be concerns that changes in sleep architecture (including a decrease in stage 2 sleep, rapid eye movement [REM] sleep, and slow wave sleep) may lead to excess weight gain in the long run [68], there is no evidence that Muslims who wake up for night prayers are necessarily REM-deprived as long as they had slept for 7 to 8 hours.

Several narrations suggest that early bedtime and early morning awakening is encouraged in Islam. 'To Allah belongs the Kingdom of the heavens and the earth. Allah has power over all things. Surely, in the creation of the heavens and the earth, and in the alternation of night and day, there are signs for those with minds. Those who remember Allah when standing, sitting, and on their sides, and contemplate upon the creation of the heavens and the earth (saying:) 'Lord, You have not created these in falsehood. Exaltations to You! Guard us against the punishment of the Fire.(Al 'Imran: 189-191). They slept but a little at night, and at dawn would ask forgiveness.(Ath-Thariyat: 17-18). As for the night there is a voluntary deed for you to keep vigil in part it. Perhaps your Lord will raise you to a praiseworthy station. (Al-'Isra' 79).

Narrated by Bukhari and Muslim in their hadiths narrated from Abu Barza Aslami may Allah be pleased with him: "The Messenger of Allah, peace be upon him, hated sleeping before Isha." "The dearest of prayer to Allah is the prayer of Dawood (peace be upon him). He used to sleep for half the night, get up and pray for one third of it, and sleep for one sixth of it".

Implications for Treatment

The Islamic literature provides numerous clues to living a healthy lifestyle [13]. These interventions were utilized in the days of the Prophet (pbuh), and some of them have been proven to be scientifically beneficial in preventing obesity and/or obesity-related disorders. Strategies such as eating less or controlling the amount of food consumed, sharing meals in groups, eating fruits and plant extracts (lady's mantle, cumin, sorting menthe, and olive), fasting intermittently, consuming milk, breastfeeding, and exercising have been shown to be helpful in weight loss; however, the effectiveness of these strategies should be further investigated. Although cross-sectional and longitudinal studies have revealed a great breadth of knowledge regarding lifestyle interventions and their effect on body weight, randomized controlled trials would provide stronger evidence regarding the efficacy of these interventions.

Further considerations should be given to investigate the association between religiosity and body weight among Muslims, as most of the research on this topic was conducted among Christian populations. While some authors [69,70] found a positive association between religiosity and weight loss, other researchers [71,72] reported a negative association, with religious practices being associated with weight gain. However, findings from a recent report [73] conducted on Latino church leaders from 18 churches in San Antonio, Texas demonstrated the strong potential of faith-based communities to serve as an intervention setting for implementing successful obesity-prevention strategies. Bearing this in mind, we believe that the rising prevalence of obesity and obesity-related disorders in Muslim countries underscores the need for such studies to be conducted among followers of Islam. Areas that need further research are summarized in table 1.

Conclusion

Although recent technological advances have permitted scientists to understand and develop treatments against obesity, its prevalence is still increasing worldwide. Effective treatment options are limited by the adverse effects associated with pharmacotherapy and surgery, and until now, lifestyle interventions, which had been encouraged in Islam several decades ago, remain the cornerstone of treatment. However, research is still lacking in that there is no strong scientific evidence to support the efficacy of these strategies. Advances in obesity treatment may be achieved if Muslim scholars and scientists work together to explore the effect of the Islamic way of life on obesity. In the future, randomized controlled trials should be conducted to assess the long-term effects of lifestyle interventions suggested in Islam.

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