Chrononutrition in the context of Ramadan: Potential implications.

Every year, healthy adult Muslims practice dawn to sunset fasting for a whole lunar month. No food or fluid is allowed for the fasting time window. After sunset, eating is allowed. The dramatic change in the timing of meals is accompanied by changes in sleeping hours and thus alterations in circadian rhythms. Hormonal mechanisms mainly determined by the latter also change. These include shifts in cortisol and melatonin. Food-dependent hormones such as Ghrelin and leptin also show changes. A well-established principle of chrononutrition is that the timing of eating may be as or more important than the content of food. Ramadan fasting (RF) is distinct from other forms of intermittent fasting, although there are also some similarities with time restricted eating (TRE). Both have been shown to have health benefits. Here, we examine existing literature to understand and learn from this very commonly practiced form of fasting and its relationships to circadian rhythms and homoeostatic mechanisms.

Ramadan Fasting and Changes in Thyroid Function in Hypothyroidism: Identifying Patients at Risk.

Background: Ramadan fasting (RF) is associated with major changes in meal times. This can affect thyroxine absorption and thyroid function (TF) in patients with hypothyroidism. We aimed to examine the short- and long-term impact of RF on TF in patients with primary hypothyroidism on levothyroxine. Methods: TF tests in patients with primary hypothyroidism attending an endocrine center in the United Arab Emirates were retrospectively analyzed. The impact of RF on TF, namely serum thyrotropin (TSH) TSH, free thyroxine (fT4) and free triiodothyronine (fT3), was investigated in 481 patients within 3 months before Ramadan (BR), 1-2 weeks (PR1), and 3-6 months (PR2) post-Ramadan. Controlled TF was defined as TSH between 0.45 and 4.5 µIU/mL. Inadequate control was defined as TSH >4.5 µIU/mL. Loss of control was defined as having controlled TF at BR and inadequate control at PR1. Multivariable regression analyses were used to assess the association of baseline TSH, baseline levothyroxine dose, and medication use with loss of thyroid control in Ramadan. Results: TSH increased significantly from a median of 2.0 (0.8-3.7) µIU/mL at BR to 2.9 (1.4-5.6) µIU/mL at PR1 (p < 0.001). This was accompanied by a fall in fT4 and fT3 at PR1 (p < 0.001). 25.5% of patients with previously controlled TF at BR had deterioration in TF at PR1. Sixty-one percent of patients with previously uncontrolled TF at BR remained uncontrolled at PR1. Baseline TSH was significantly associated with loss of thyroid control in Ramadan with an odds ratio (95% confidence interval) of 1.5 (1.17-1.92) (p < 0.001), whereas other variables, including medications known to affect levothyroxine absorption were not associated with loss of control. TSH, fT4, and fT3 levels returned to normal at PR2. Conclusions: RF can negatively affect TF of patients on levothyroxine replacement. Although this effect is modest and transitory in most patients, a significant minority exhibit more pronounced, and clinically relevant changes. The latter includes those with higher TSH BR, and a smaller group whose thyroid disease appears to be particularly affected by the mealtime and lifestyle changes of Ramadan.

Diabetes and Ramadan: Practical guidelines 2021.

Fasting during Ramadan is one of the five pillars of Islam and is obligatory for all healthy Muslims from the age of puberty. Though individuals with some illness and serious medical conditions, including some people with diabetes, can be exempted from fasting, many will fast anyway. It is of paramount importance that people with diabetes that fast are given the appropriate guidance and receive proper care. The International Diabetes Federation (IDF) and Diabetes and Ramadan (DaR) International Alliance have come together to provide a substantial update to the previous guidelines. This update includes key information on fasting during Ramadan with type 1 diabetes, the management of diabetes in people of elderly ages and pregnant women, the effects of Ramadan on one's mental wellbeing, changes to the risk of macrovascular and microvascular complications, and areas of future research. The IDF-DAR Diabetes and Ramadan Practical Guidelines 2021 seek to improve upon the awareness, knowledge and management of diabetes during Ramadan, and to provide real-world recommendations to health professionals and the people with diabetes who choose to fast.

Alterations in ß-Cell Sphingolipid Profile Associated with ER Stress and iPLA2ß: Another Contributor to ß-Cell Apoptosis in Type 1 Diabetes.

Type 1 diabetes (T1D) development, in part, is due to ER stress-induced ß-cell apoptosis. Activation of the Ca2+-independent phospholipase A2 beta (iPLA2ß) leads to the generation of pro-inflammatory eicosanoids, which contribute to ß-cell death and T1D. ER stress induces iPLA2ß-mediated generation of pro-apoptotic ceramides via neutral sphingomyelinase (NSMase). To gain a better understanding of the impact of iPLA2ß on sphingolipids (SLs), we characterized their profile in ß-cells undergoing ER stress. ESI/MS/MS analyses followed by ANOVA/Student's t-test were used to assess differences in sphingolipids molecular species in Vector (V) control and iPLA2ß-overexpressing (OE) INS-1 and Akita (AK, spontaneous model of ER stress) and WT-littermate (AK-WT) ß-cells. As expected, iPLA2ß induction was greater in the OE and AK cells in comparison with V and WT cells. We report here that ER stress led to elevations in pro-apoptotic and decreases in pro-survival sphingolipids and that the inactivation of iPLA2ß restores the sphingolipid species toward those that promote cell survival. In view of our recent finding that the SL profile in macrophages-the initiators of autoimmune responses leading to T1D-is not significantly altered during T1D development, we posit that the iPLA2ß-mediated shift in the ß-cell sphingolipid profile is an important contributor to ß-cell death associated with T1D.

Weight and Glycemic Control Outcomes of Bariatric Surgery and Pharmacotherapy in Patients With Melanocortin-4 Receptor Deficiency.

Background: Melanocortin-4 receptor (MC4R) mutations are the most common of the rare monogenic forms of obesity. However, the efficacy of bariatric surgery (BS) and pharmacotherapy on weight and glycemic control in individuals with MC4R deficiency (MC4R-d) is not well-established. We investigated and compared the outcomes of BS and pharmacotherapy in patients with and without MC4R-d. Methods: Pertinent details were derived from the electronic database among identified patients who had BS with MC4R-d (study group, SG) and wild-type controls (age- and sex-matched control group, CG). Short- and long-term outcomes were reported for the SG. Short-term outcomes were compared between the two groups. Results: Seventy patients were screened for MC4R-d. The SG [six individuals (four females, two males); 18 (10-27) years old at BS; 50.3 (41.8-61.9) kg/m2 at BS, three patients with homozygous T162I mutations, two patients with heterozygous T162I mutations, and one patient with heterozygous I170V mutation] had a follow-up duration of up to 10 years. Weight loss, which varied depending on mutation type [17.99 (6.10-22.54) %] was stable for 6 months; heterogeneity of results was observed thereafter. BS was found superior to liraglutide on weight and glycemic control outcomes. At a median follow-up of 6 months, no significant difference was observed on weight loss (20.8% vs. 23.0%, p = 0.65) between the SG and the CG [eight individuals (four females, four males); 19.0 (17.8-36.8) years old at BS, 46.2 (42.0-48.3) kg/m2 at BS or phamacotherapeutic intervention]. Glycemic control in patients with MC4R-d and Type 2 diabetes improved post-BS. Conclusion: Our data indicate efficacious short-term but varied long-term weight loss and glycemic control outcomes of BS on patients with MC4R-d, suggesting the importance of ongoing monitoring and complementary therapeutic interventions.

Ramadan fasting in insulin-treated patients is associated with potentially unfavourable changes in glucose metrics: A flash glucose monitoring (FGM) study.

AIM(S): Ramadan fasting (RF) can represent various challenges to glycaemic control especially in insulin-treated patients with diabetes. We aimed to assess the effect of RF on several glucose metrics using flash glucose monitoring (FGM). METHODS: Complete FGM data for 29-30 days before, during and after Ramadan were available for 40 patients with type 1 (n = 13) and type 2 diabetes (n = 27) on insulin (with or without oral hypoglycaemic) treatment. Indicators of mean glucose, glucose variability (GV) and time in different glycaemic ranges were analysed. RESULTS: RF was associated with increase in time in hyperglycaemia (38.5 ± 18.2 vs 48.7 ± 20.7%; P < 0.001) and decrease in time in hypoglycaemia (3.2 ± 2.8 vs 2.1 ± 2.1%; P = 0.003), and time in target range (56.3 ± 17.2 vs 47.9 ± 19.7%, P < 0.001). There were no significant differences in markers of GV with RF; however, RF was associated with a significant reduction in GV during the day but not night time with an increase in the ensuing non-fasting period. CONCLUSIONS: In insulin-treated patients, RF is associated with an increase in time in hyperglycaemia, a reduced time in target range and nocturnal increase in GV, indicating a need for more refined management algorithms.

Sphingolipid Metabolism in Glioblastoma and Metastatic Brain Tumors: A Review of Sphingomyelinases and Sphingosine-1-Phosphate.

Glioblastoma (GBM) is a primary malignant brain tumor with a dismal prognosis, partially due to our inability to completely remove and kill all GBM cells. Rapid tumor recurrence contributes to a median survival of only 15 months with the current standard of care which includes maximal surgical resection, radiation, and temozolomide (TMZ), a blood-brain barrier (BBB) penetrant chemotherapy. Radiation and TMZ cause sphingomyelinases (SMase) to hydrolyze sphingomyelins to generate ceramides, which induce apoptosis. However, cells can evade apoptosis by converting ceramides to sphingosine-1-phosphate (S1P). S1P has been implicated in a wide range of cancers including GBM. Upregulation of S1P has been linked to the proliferation and invasion of GBM and other cancers that display a propensity for brain metastasis. To mediate their biological effects, SMases and S1P modulate signaling via phospholipase C (PLC) and phospholipase D (PLD). In addition, both SMase and S1P may alter the integrity of the BBB leading to infiltration of tumor-promoting immune populations. SMase activity has been associated with tumor evasion of the immune system, while S1P creates a gradient for trafficking of innate and adaptive immune cells. This review will explore the role of sphingolipid metabolism and pharmacological interventions in GBM and metastatic brain tumors with a focus on SMase and S1P.

Diabetes and Ramadan: Utility of flash-glucose monitoring derived markers of glycaemic control and comparison with glycosylated haemoglobin.

AIMS: Flash glucose monitoring (FGM)-derived markers of glucose control and variability and laboratory measured HbA1c among patients with diabetes on insulin in context of Ramadan fasting (RF) were examined and compared. METHODS: FGM data on insulin-treated patients (n = 20, age 42.3 ±â€¯11.4 years; 18 male, 2 female; 13 with type 1 and 7 with type 2 diabetes) who fasted during Ramadan were used to calculate Q-score as an indicator of glycaemia before, during and after RF. Post-hoc analysis in a group of patients (n = 12) who had HbA1c available and appropriate for these periods was performed. Other relevant data were extracted from patient records. RESULTS: Mean glucose (9.6 ±â€¯1.32 v 10.78 ±â€¯1.64 mmol/l; P < 0.0001) and Q-score increased significantly with Ramadan fasting and reduced after Ramadan. Post-hoc subgroup analysis showed a significant rise in eA1c (7.2 ±â€¯0.4%; 55.0 ±â€¯4.4 mmol/mol v 7.7 ±â€¯0.5%; 61.0 ±â€¯5.5 mmol/mol) but not in laboratory HbA1c with Ramadan fasting; eA1c reduced after Ramadan (P = 0.018). CONCLUSIONS: Ramadan fasting was associated with a deterioration in overall glucose control and time in hyperglycaemia in insulin-treated patients. FGM-derived markers are useful and a preferable alternative to HbA1c in Ramadan studies.

Energy Metabolism and Intermittent Fasting: The Ramadan Perspective.

Intermittent fasting (IF) has been gaining popularity as a means of losing weight. The Ramadan fast (RF) is a form of IF practiced by millions of adult Muslims globally for a whole lunar month every year. It entails a major shift from normal eating patterns to exclusive nocturnal eating. RF is a state of intermittent liver glycogen depletion and repletion. The earlier (morning) part of the fasting day is marked by dominance of carbohydrate as the main fuel, but lipid becomes more important towards the afternoon and as the time for breaking the fast at sunset (iftar) gets closer. The practice of observing Ramadan fasting is accompanied by changes in sleeping and activity patterns, as well as circadian rhythms of hormones including cortisol, insulin, leptin, ghrelin, growth hormone, prolactin, sex hormones, and adiponectin. Few studies have investigated energy expenditure in the context of RF including resting metabolic rate (RMR) and total energy expenditure (TEE) and found no significant changes with RF. Changes in activity and sleeping patterns however do occur and are different from non-Ramadan days. Weight changes in the context of Ramadan fast are variable and typically modest with wise inter-individual variation. As well as its direct relevance to many religious observers, understanding intermittent fasting may have implications on weight loss strategies with even broader potential implications. This review examines current knowledge on different aspects of energy balance in RF, as a common model to learn from and also map out strategies for healthier outcomes in such settings.

Calcium-independent phospholipases A2 and their roles in biological processes and diseases.

Among the family of phospholipases A2 (PLA2s) are the Ca(2+)-independent PLA2s (iPLA2s) and they are designated group VI iPLA2s. In relation to secretory and cytosolic PLA2s, the iPLA2s are more recently described and details of their expression and roles in biological functions are rapidly emerging. The iPLA2s or patatin-like phospholipases (PNPLAs) are intracellular enzymes that do not require Ca(2+) for activity, and contain lipase (GXSXG) and nucleotide-binding (GXGXXG) consensus sequences. Though nine PNPLAs have been recognized, PNPLA8 (membrane-associated iPLA2γ) and PNPLA9 (cytosol-associated iPLA2ß) are the most widely studied and understood. The iPLA2s manifest a variety of activities in addition to phospholipase, are ubiquitously expressed, and participate in a multitude of biological processes, including fat catabolism, cell differentiation, maintenance of mitochondrial integrity, phospholipid remodeling, cell proliferation, signal transduction, and cell death. As might be expected, increased or decreased expression of iPLA2s can have profound effects on the metabolic state, CNS function, cardiovascular performance, and cell survival; therefore, dysregulation of iPLA2s can be a critical factor in the development of many diseases. This review is aimed at providing a general framework of the current understanding of the iPLA2s and discussion of the potential mechanisms of action of the iPLA2s and related involved lipid mediators.

Inhibition of Ca2+-independent phospholipase A2ß (iPLA2ß) ameliorates islet infiltration and incidence of diabetes in NOD mice.

Autoimmune ß-cell death leads to type 1 diabetes, and with findings that Ca(2+)-independent phospholipase A2ß (iPLA2ß) activation contributes to ß-cell death, we assessed the effects of iPLA2ß inhibition on diabetes development. Administration of FKGK18, a reversible iPLA2ß inhibitor, to NOD female mice significantly reduced diabetes incidence in association with 1) reduced insulitis, reflected by reductions in CD4(+) T cells and B cells; 2) improved glucose homeostasis; 3) higher circulating insulin; and 4) ß-cell preservation. Furthermore, FKGK18 inhibited production of tumor necrosis factor-α (TNF-α) from CD4(+) T cells and antibodies from B cells, suggesting modulation of immune cell responses by iPLA2ß-derived products. Consistent with this, 1) adoptive transfer of diabetes by CD4(+) T cells to immunodeficient and diabetes-resistant NOD.scid mice was mitigated by FKGK18 pretreatment and 2) TNF-α production from CD4(+) T cells was reduced by inhibitors of cyclooxygenase and 12-lipoxygenase, which metabolize arachidonic acid to generate bioactive inflammatory eicosanoids. However, adoptive transfer of diabetes was not prevented when mice were administered FKGK18-pretreated T cells or when FKGK18 administration was initiated with T-cell transfer. The present observations suggest that iPLA2ß-derived lipid signals modulate immune cell responses, raising the possibility that early inhibition of iPLA2ß may be beneficial in ameliorating autoimmune destruction of ß-cells and mitigating type 1 diabetes development.

Evidence of contribution of iPLA2ß-mediated events during islet ß-cell apoptosis due to proinflammatory cytokines suggests a role for iPLA2ß in T1D development.

Type 1 diabetes (T1D) results from autoimmune destruction of islet ß-cells, but the underlying mechanisms that contribute to this process are incompletely understood, especially the role of lipid signals generated by ß-cells. Proinflammatory cytokines induce ER stress in ß-cells and we previously found that the Ca(2+)-independent phospholipase A2ß (iPLA2ß) participates in ER stress-induced ß-cell apoptosis. In view of reports of elevated iPLA2ß in T1D, we examined if iPLA2ß participates in cytokine-mediated islet ß-cell apoptosis. We find that the proinflammatory cytokine combination IL-1ß+IFNγ, induces: a) ER stress, mSREBP-1, and iPLA2ß, b) lysophosphatidylcholine (LPC) generation, c) neutral sphingomyelinase-2 (NSMase2), d) ceramide accumulation, e) mitochondrial membrane decompensation, f) caspase-3 activation, and g) ß-cell apoptosis. The presence of a sterol regulatory element in the iPLA2ß gene raises the possibility that activation of SREBP-1 after proinflammatory cytokine exposure contributes to iPLA2ß induction. The IL-1ß+IFNγ-induced outcomes (b-g) are all inhibited by iPLA2ß inactivation, suggesting that iPLA2ß-derived lipid signals contribute to consequential islet ß-cell death. Consistent with this possibility, ER stress and ß-cell apoptosis induced by proinflammatory cytokines are exacerbated in islets from RIP-iPLA2ß-Tg mice and blunted in islets from iPLA2ß-KO mice. These observations suggest that iPLA2ß-mediated events participate in amplifying ß-cell apoptosis due to proinflammatory cytokines and also that iPLA2ß activation may have a reciprocal impact on ER stress development. They raise the possibility that iPLA2ß inhibition, leading to ameliorations in ER stress, apoptosis, and immune responses resulting from LPC-stimulated immune cell chemotaxis, may be beneficial in preserving ß-cell mass and delaying/preventing T1D evolution.

Characterization of FKGK18 as inhibitor of group VIA Ca2+-independent phospholipase A2 (iPLA2ß): candidate drug for preventing beta-cell apoptosis and diabetes.

Ongoing studies suggest an important role for iPLA2ß in a multitude of biological processes and it has been implicated in neurodegenerative, skeletal and vascular smooth muscle disorders, bone formation, and cardiac arrhythmias. Thus, identifying an iPLA2ßinhibitor that can be reliably and safely used in vivo is warranted. Currently, the mechanism-based inhibitor bromoenol lactone (BEL) is the most widely used to discern the role of iPLA2ß in biological processes. While BEL is recognized as a more potent inhibitor of iPLA2 than of cPLA2 or sPLA2, leading to its designation as a "specific" inhibitor of iPLA2, it has been shown to also inhibit non-PLA2 enzymes. A potential complication of its use is that while the S and R enantiomers of BEL exhibit preference for cytosol-associated iPLA2ß and membrane-associated iPLA2γ, respectively, the selectivity is only 10-fold for both. In addition, BEL is unstable in solution, promotes irreversible inhibition, and may be cytotoxic, making BEL not amenable for in vivo use. Recently, a fluoroketone (FK)-based compound (FKGK18) was described as a potent inhibitor of iPLA2ß. Here we characterized its inhibitory profile in beta-cells and find that FKGK18: (a) inhibits iPLA2ß with a greater potency (100-fold) than iPLA2γ, (b) inhibition of iPLA2ß is reversible, (c) is an ineffective inhibitor of α-chymotrypsin, and (d) inhibits previously described outcomes of iPLA2ß activation including (i) glucose-stimulated insulin secretion, (ii) arachidonic acid hydrolysis; as reflected by PGE2 release from human islets, (iii) ER stress-induced neutral sphingomyelinase 2 expression, and (iv) ER stress-induced beta-cell apoptosis. These findings suggest that FKGK18 is similar to BEL in its ability to inhibit iPLA2ß. Because, in contrast to BEL, it is reversible and not a non-specific inhibitor of proteases, it is suggested that FKGK18 is more ideal for ex vivo and in vivo assessments of iPLA2ß role in biological functions.

Genetic modulation of islet ß-cell iPLA2ß expression provides evidence for its impact on ß-cell apoptosis and autophagy.

ß-cell apoptosis is a significant contributor to ß-cell dysfunction in diabetes and ER stress is among the factors that contributes to ß-cell death. We previously identified that the Ca²âº-independent phospholipase A2ß (iPLA2ß), which in islets is localized in ß-cells, participates in ER stress-induced ß-cell apoptosis. Here, direct assessment of iPLA2ß role was made using ß-cell-specific iPLA2ß overexpressing (RIP-iPLA2ß-Tg) and globally iPLA2ß-deficient (iPLA2ß-KO) mice. Islets from Tg, but not KO, express higher islet iPLA2ß and neutral sphingomyelinase, decrease in sphingomyelins, and increase in ceramides, relative to WT group. ER stress induces iPLA2ß, ER stress factors, loss of mitochondrial membrane potential (∆Ψ), caspase-3 activation, and ß-cell apoptosis in the WT and these are all amplified in the Tg group. Surprisingly, ß-cells apoptosis while reduced in the KO is higher than in the WT group. This, however, was not accompanied by greater caspase-3 activation but with larger loss of ∆Ψ, suggesting that iPLA2ß deficiency impacts mitochondrial membrane integrity and causes apoptosis by a caspase-independent manner. Further, autophagy, as reflected by LC3-II accumulation, is increased in Tg and decreased in KO, relative to WT. Our findings suggest that (1) iPLA2ß impacts upstream (UPR) and downstream (ceramide generation and mitochondrial) pathways in ß-cells and (2) both over- or under-expression of iPLA2ß is deleterious to the ß-cells. Further, we present for the first time evidence for potential regulation of autophagy by iPLA2ß in islet ß-cells. These findings support the hypothesis that iPLA2ß induction under stress, as in diabetes, is a key component to amplifying ß-cell death processes.

Tumor suppressor Pdcd4 is a major transcript that is upregulated during in vivo pancreatic islet neogenesis and is expressed in both beta-cell and ductal cell lines.

OBJECTIVES: We wished to identify a major transcript that is upregulated during in vivo pancreatic islet neogenesis and examine the expression of the gene in beta and ductal cells. METHODS: Differential display polymerase chain reaction was used to identify upregulated transcripts after islet neogenesis was stimulated in the rat by brief occlusion of the main pancreatic duct. The expression of this major transcript, namely PDCD4 (programmed cell death gene 4), was measured in beta and ductal cells after stimulation with the incretin hormone glucagon-like peptide 1, mitogenic insulin, the thiazolidinedione rosiglitazone, and by high glucose concentrations. The subcellular location of the protein was also examined. RESULTS: The expression of the Pdcd4 gene in pancreatic beta and ductal cells was found to be stimulated in a comparable manner by either glucagon-like peptide 1, insulin, and by high glucose concentrations. However, intracellular localisation of the PDCD4 protein was shown to be differentially regulated by these stimuli in beta and ductal cells. Furthermore, the thiazolidinedione rosiglitazone specifically upregulates Pdcd4 gene expression in beta cells in a time-dependent manner. CONCLUSION: This is the first study showing Pdcd4 expression in pancreatic cells. Our data indicate that Pdcd4 expression may be integral in the function of the adult pancreas.

Selenium stimulates pancreatic beta-cell gene expression and enhances islet function.

The present study investigated the role of selenium in the regulation of pancreatic beta-cell function. Utilising the mouse beta-cell line Min6, we have shown that selenium specifically upregulates Ipf1 (insulin promoter factor 1) gene expression, activating the -2715 to -1960 section of the Ipf1 gene promoter. Selenium increased both Ipf1 and insulin mRNA levels in Min6 cells and stimulated increases in insulin content and insulin secretion in isolated primary rat islets of Langerhans. These data are the first to implicate selenium in the regulation of specific beta-cell target genes and suggest that selenium potentially promotes an overall improvement in islet function.