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SEVAMED GUEST ARTICLE

Fasting- Integrating Ancient Wisdom and Modern Insights for Positive Health

Dr. Mukund Baheti*, Dr. Praveen Khairkar**

Introduction:

“The zealous display the strength of their belief, while the judicious show the grounds of it.” -
William Shenstone, 18th Century Poet  

‘Fasting’ is much more than simply not eating; it is both a science and art. It has meaning, in terms of overall well being and affects the psychological and emotional aspects of our lives. The word comes from the old English word fasten, which means firm or fixed. In other words, the fast is something we hold on to a firm basis under controlled and fixed conditions. Those who think that fasting is equivalent to starvation are entirely wrong. There are basically two periods, fasting continues so long as the body supports itself on the stored reserves within its tissues while starvation (it is derived from Anglo-Saxon stearfan, which means to die) begins when abstinence is carried beyond the time when the reserves are used up or have dropped to a dangerously low level.

In animal world fasting is highly important factor for existence. Animal fast not only when sick or wounded but also during hibernation or aestivation (sleeping throughout the summer in tropical climates.) Some animals fast during mating season and in many cases during the nursing period. Some birds fast while their eggs are being hatched. Some animals fast immediately after birth. There are forms of spider that do not eat for six months after they are born. Some wild creatures fast when taken into captivity and we know how our domestic pet like dog or a cat may not eat for several days when it comes into a new environment. In mankind fasting has been practiced in various parts of the world over the centuries for religious reasons, for self-discipline, for political purpose. Fasting or calorie restriction (CR) had been termed as “hunger cure” by early German & Indian nature scientists which is honoured with exceedingly beneficial effects in great number of diseases and prolongs aging. Authors would like to examine and discuss briefly fundamental areas where total fasting (with the exception of drinking water) can play a crucial role.

Scientific observations for implications of fasting/Calorie restriction:
In March, 1963, newspapers around the world described the almost incredible story of seven weeks deprivation of food and survival of Ralph Flores (42 years old pilot from California) and Helen Klaben (21 year old co-editor of Brooklyn New York) following plane crash on mountain side of Northen British Columbia. Couple were rescued after 49 days in wilderness in the dead of winter, over 35 days of this time they were without any food at all. Except for losing 40 pounds, physicians who examined them after rescue, found them to be in “remarkably good” condition. One of the distinguished biochemist, an authority on nutrition and a Nobel Laureate from Sweden, Dr. Ragnar Berg says “one can fast a long time; we know of fasts of over a hundred days duration, so we have no need of fearing that we will die of hunger.” So actual time period of abstinence forced on Mr. Flores and Miss Klaben was of relatively moderate duration. The question is not how long man can fast, but what are the provision(s) of nature that enable him/her to do so.

The normal body provides itself with a store of nutritive materials that are put away in the form of glycogen, fat, muscle juices, bone marrow, minerals and vitamins. These stored reserves are made available to vital organs through a process called autolysis, as needed. It is significant to note that, even in prolonged fasts, no beriberi, pellagra, rickets, scurvy or other “deficiency diseases” ever develops, thus showing that the reserves of the body are generally well balanced. (1,2)

However, medical literature evidence shows that fasting or calorie restriction (CR) retards aging and extends median and maximal life span was first presented in the 1930s by McCay et al (3). Since then, similar observations have been made in a variety of species including rats, mice, fish, flies, worms, and yeast (3). Although not yet definitive, results from the ongoing calorie-restriction studies in monkeys also suggest that the mortality rate in calorie-restricted animals will be lower than that in control subjects (4,5). Furthermore, calorie-restricted monkeys also have higher concentrations of dehydroepiandrosterone sulphate, which is suspected to be a marker of longevity in humans (6), although this is not observed consistently (7). In humans, a few observational studies reported the effects of prolonged CR, in the context of high-quality diets, on health and longevity. Kagawa (8) carefully analyzed data documenting the prevalence of centenarians on the island of Okinawa (Japan). Total energy consumed by schoolchildren on Okinawa was only 62% of the “recommended intake” for Japan as a whole. For adults, total protein and lipid intakes were about the same, but energy intake was 20% less than the Japanese national average. The rates of death due to cerebral vascular disease, malignancy, and heart disease on Okinawa were only 59%, 69%, and 59%, respectively, of those for the rest of Japan. Whereas these data are consistent with the hypothesis that CR increases life span in humans, there probably are other, unmeasured differences between Okinawa and mainland Japan, including genetic or other environmental factors. However, Okinawans who move away from the island (and presumably abandon their protective lifestyle patterns) have mortality rates higher than those in Okinawans who remain on the island (9).

To our knowledge, only one study investigated the effects of long-term calorie restriction (with a diet of reasonable quality) on health and longevity in nonobese humans and a control group (10). This study was conducted in 120 men, of whom 60 were randomly assigned to the control group and 60 to the calorie-restricted group. The control group was fed ≈9600 kJ/d. Calorie-restricted subjects received 1 L milk and 500 g fruit every other day, which led to an overall mean energy intake of ≈6300 kJ/d (or a 35% restriction from the intake of the control group). This regimen was implemented for almost 3 years. Interestingly, Stunkard (11) reanalyzed these data after 7 years and reported less time in the infirmary (123 compared with 219 d) and a non-significant difference in the death rate (6 compared with 13 deaths) in calorie-restricted subjects than in control subjects, respectively, which suggests that chronic CR may prolong life span in humans. Numerous changes in physiologic, hematologic, hormonal, and biochemical variables were observed (12). These changes mimic many of the effects previously observed in rodent calorie-restriction studies, but they cannot be equated with increased longevity in non-obese humans.

It is also not known whether creating a relative energy deficit by increasing physical activity (PA) without modifying other health behaviors will increase life span. Increased activity (to achieve a relative energy deficit of 30%) did not extend maximal life span in rodents, although average life span was increased (13). Increased activity was also associated with some traits of CR, including improved insulin sensitivity, decreased fat mass (FM), and reduced tumor incidence. Holloszy (14) observed that adding PA to CR did not interfere with the life-extension effects of CR. As of now, no data exist on whether PA (or a combination of CR and PA) will extend life span in humans. One of the observational studies suggest that PA improves the quality of life and prevents the onset of chronic disease (15). Increasing PA to create a relative energy deficit may improve compliance and may be associated with a lower rate of attrition in humans.

Molecular Mechanisms /Gene Expression in fasting:
Many of the effects of prolonged fasting have been characterized but the mechanism or mechanisms by which it increases life span are still debated. An initial hypothesis was that delayed sexual maturation might be one of those mechanisms through which fasting exerts its effect on longevity, until it was shown that fasting initiated in older animals also extends life span (16). Reduced metabolic rate is another possible explanation for the anti-aging effects of fasting, with the consequent reduction in free radicals underpinning this observation. However, many other metabolic alterations are associated for instance; short-term fasting in humans and long-term fasting in animals alter insulin sensitivity, the secretion of many hormones, increases the number of gut microbiota genus called lactobacillus which have been reported to benefit gut barrier function by preventing endotoxins from passing into bloodstream and alleviating the sympathetic nervous system activity.(17) Fasting in essence affects DNA methylation and histone modification thereby regulating the key genes like ras, P53 and so on and also alters these gene expression profiles in muscle, heart, and brain. Gene expression profiling today with the use of DNA microarrays has revealed that aging is associated with several alterations in gene expression in rodent skeletal muscle, brain, and heart and that fasting prevents many of these changes. (18)

Does fasting really cure?:
There is no clear and universal answer to certain questions and this is one of it.  One of the leading practitioners in the field of fasting George Weger, MD, Director of Weger Health School, Redlands, California wrote in his book “The Genesis and Control of Disease” that “the author is willing to side with the enlarging minority and believe in the efficacy of the fast. Facts will not down, nothing is more gratifying or no work is more inspiring than to actually witness complete recovery during comparatively short periods of fasting in diseases such as chronic eczema, urticaria, varicose ulcers, gastric and duodenal ulcers, asthma, arthritis, colitis, endocarditis, sinusitis, bronchitis, neuritis, trigeminal neuralgia, urinary and biliary calculi, glaucoma, migraine, lump on the breast, epilepsy, paralysis agitans, Reynaud’s disease and even locomotor ataxia.“ His conclusions are based upon actual group results. Many will say, ‘preposterous!’ others might say there is no such thing as a ‘Cure all’; others may damn with faint praise. To all doubters we must say in all seriousness that fasting and a diet properly selected  and combined, are the nearest approach to a ‘Cure-All’ that is possible to conceive- profoundly simple and simply profound. So Let us discuss some of the medical disorders and the role of fasting in their management.

The fast and Migraine:
One of the treatment resistant chronic migraine patients told to one of the author (MB) while taking consultation “I had received all the forms of available treatment for sufficient duration that various disciplines of medicines can offer but I had never received more than brief periods of evanescent relief. I know that my headaches are due to constipation and if I could get rid of constipation, I would not suffer with headache.” When therapist evaluated her medical records and treatment he could see her demoralizing life with migraine however, he replied and explained to her that headache is a symptom and a constipation is also a symptom and that symptoms do not cause each other, we have to find common cause of both symptom and since all investigations were normal, let’s try a short fast to enable her encumbered body to unload its accumulated toxins and remove the cause of her sufferings. A week later she reported no more headaches and her constipation ended at the same time. Dr. Walter Alvarez and Dr. Weger in their profound observation supported the theory of toxaemia for migraine headache or periodic cephalalgia. However, there are plenty reports of migraine being exacerbated by fasting rituals like Ramazan. (19)

The fast and the Heart:
It is said authoritatively by Dr. Hereward Carrington, Ph.D., author of Vitality, Fasting and Nutrition that the heart is invariably strengthened and invigorated by fasting is true beyond doubt. He goes on to take the stand that fasting is the greatest of all strengtheners of weak hearts as it is openly rational physiological care. Angina pectoris, one of the most common disease of the heart that grows out of constant stimulation with tobacco, coffee, tea, wrong food combinations and excess of carbohydrates. If we observe the effects of fast in these patients, we are amazed at the speed with which the heart recovers from its difficulties. In past thirty years or so, more than ninety drugs and surgical treatments have been advocated for world’s first cause of mortality. At the same time angina has been called a “self-limiting disease,” and looking at its ghastly state, how do we know that fasting is of genuine value? A blind Canadian cardiologist and authority in world said that “a murmur or ticker has certainly improved and slowed down immediately after few days of fasting taking the load off so that it may restore its own normal condition in more certain and speedy manner. It is a period of physiological rest, it does not do anything, it is merely a cessation of doing. The rest provides opportunity for the nature of body to do it for yourself, under the condition of rest, what it cannot do under conditions of full-speed ahead. One of the study by Young, Mullen and Lidsberg (20) in 1978 reported that in the spontaneously hypertensive rats, caloric restriction without sodium restriction is associated with reduced blood pressure. Four days of fasting lowered blood pressure 19% while 4 days of eating 50% of ad lib intake reduced blood pressure 10%. These data are consistent with the hypothesis that caloric restriction lowers sympathetic activity.
An Italian physician, Giorgio Dagnini, MD., studied the results of fasting in 16 cases of cardiac decompensations of either gender (3 of them had mitral regurgitation, 6 of them had severe mitral stenosis, 2 of them had severe aortic stenosis, 2 of them had malignant hypertension, and most (12) of them had edema of serous cavities or were in congestive cardiac failure). Their ages ranged from 24 years to 75 years. In his trial, the fast ranged from five days the shortest to seven days the longest. He observed that by third day of fast most of them began improving in their cardiac decompensation.  In one of his patient of mitral stenosis with right heart failure, anasarca and liver enlarged to iliac crest, on day 7, liver was but three finger breadths below ribs and generalized edema completely disappeared. However, his fasts were of short duration, not long enough for complete results and he fails to tell us how they were followed up. In their extensive review, Zoltan et al revealed that attenuation of the products of reactive oxygen species and inhibition of inflammatory pathways suppresses the initiation or progression of cardiovascular diseases. (21)

Cancer and Fasting:
It was 1927, when the first “cancer week” was being celebrated in United States of America. The New York’s newspapers carried columns each day about cancer and urged all people to see their physicians for screening whosover had lumps, moles, bleeding, loss of weight and other such symptoms indicative of cancer.  One of the young patients was diagnosed with breast cancer by four different physicians at different places and urged her for immediate removal of her breast came to seek advice from Dr. Herbert Shelton who was one of the foremost authorities and acclaimed professor of Natural Hygiene advised her two weeks of fasting and to his surprise even after 13 years of follow-up, he found no traces of lump at all. There were similar reports even in case(s) of prostrate enlargements (benign or malignant?). Since biopsy could not be done, it is difficult to precisely getting convinced today. However, in 1976 in journal called ‘Nature’ published article entitled “Suppression of adenocarcinoma by immunological consequences of calorie restriction” by Gabriel Fernandes et al. (22) To confirm these effects in vivo, Lee et al (23) studied mice with subcutaneous allograft of marine cancer or xenograft of human cancer cells. They observed that 60 hours of food deprivation retards the tumour growth as effective as chemotherapy does. Their article was published in New England Journal of Medicine. Further, Valter Longo and colleagues (24) proposed that a treatment used to prolong life in some laboratory organisms could offer protection against the negative effects of chemotherapy.  That treatment is fasting. Dietary restriction provides adequate nutrition at lower-than-average calories, either through special daily meals or intermittent fasting.

Based on these observations, Longo and colleagues hypothesized that they could use this “differential stress resistance” induced by fasting to reduce chemotherapy-related stress on normal cells, without jeopardizing the treatment’s efficacy for killing cancerous cells. Initial results in mice were encouraging: the mice survived and the chemotherapy was still effective. A subsequent but still very preliminary clinical study showed that patients who fasted in conjunction with chemotherapy reported fewer side-effects without loss of efficacy. The clinical study has been expanded to an early phase clinical trial. . Energy restriction enhances DNA repair and moderates oxidative damage to DNA. Energy restriction reduces oncogene expression as well. Over a half century ago, Kritchevsky (25) noted that energy restriction in female rats resulted in adrenal hypertrophy and reduced weight of ovaries and uterus. He suggested that energy restriction resulted in "pseudohypophysectomy." We now know that adrenalectomy can negate the effects of caloric restriction.

Fasting helps resist diabetes and brain damage:
In the study, published in the Proceedings of the National Academy of Sciences Online Early Edition the week of April 28, 2003, Dr. Mattson and his colleagues(26)  investigators at the National Institute on Aging, found mice that were fasted every other day but were allowed to eat unlimited amounts on intervening days had lower blood glucose and insulin levels than either a control group, which was allowed to feed freely, or a calorically restricted group, which was fed 30 percent fewer calories daily than the control group. Despite fasting, the meal-skipping mice tended to gorge when provided food so they did not eat fewer calories than the control group. This finding in mice suggests that meal-skipping improves glucose metabolism and may provide protection against diabetes,       Dr. Mattson says. In the same study, mice on these three diets were given a neurotoxin called kainate, which damages nerve cells in a brain region called the hippocampus that is Fastingitical for learning and memory. (In humans, nerve cells in the hippocampus are destroyed by Alzheimer's disease). Dr. Mattson's team found that nerve cells of the meal-skipping mice were more resistant to neurotoxin injury or death than nerve cells of the mice on either of the other diets.

Previous studies by Dr. Halagappa Veerendra and Dr. Mattson (27) suggested that nerve cells in the brains of rodents on a meal-skipping diet are more resistant to dysfunction and death in experimental models of stroke and other neurological disorders including Parkinson's, Alzheimer's and Huntington's diseases. Dr. Mattson also has found that meal-skipping diets can stimulate brain cells in mice to produce a protein called brain-derived neurotrophic factor (BDNF) that promotes the survival and growth of nerve cells. (28)

Fasting in Psoriasis and Skin diseases:
Psoriatic and vitiligo patients frequently find themselves forced to face a situation apparently beyond help as both of them are very persistent diseases of the skin. Sometimes intense intervention by dermatologists led to fractional, glitzy recovery and nothing but more inflammation and disfigurement. A wild question aroused in authors mind: would fasting help? On investigating, we found the evidence that imprudent eating seems to affect the condition more promptly than any other self-indulgence.  Naldi et al (29) in 2014 published a famous randomized control trial in British Journal of Dermatology about 20 week qualitative and quantitative calorie restriction with physical exercise in 303 patients with psoriasis and their intention-to-treat analysis showed a median PASI (Psoriasis Area and Severity Index) reduction of 48% (95% confidence interval 33.3-58.3%) in the dietary intervention arm and 25.5% (95% confidence interval 18.2-33.3%) in the information-only arm (P = 0.02). Among secondary outcomes, PASI score reduction of ≥ 50% significantly differed between study arms (49.7% with dietary intervention vs. 34.2% with information only, P = 0.006). In an another interesting randomized clinical study published in JAMA in 2013 intervening calorie restriction inducing eight loss in psoriatic patients by Jensen et al (30) revealed a trend in favor of clinically important PASI improvement and a significant reduction in DLQI in overweight patients with psoriasis.

Fasting: how long and how to break?
Finally, if such fasts are being conducted for therapeutic purpose, the question naturally arise for how long they have to be done and naturopathy guidelines are available for most conditions or disease related programs and they must be carried out under a supervision of trained naturopathic/nutritional therapist. Surprisingly most fasts are broken before the return of hunger. There are many reasons why it is done. In a small percentage of cases, the faster is too thin or too weak to carry the fast to a natural termination. In many instances there is lack of time or funds or will to fast further. Some fasters, even when fasting solely for health reasons, object to getting so thin. Most of them are anxious to end the fast as soon as they are free of their annoying set of symptoms. There are thousand personal reasons for ending the fast short of its natural termination. The ideal moment to break the fast, of course, is at the time when hunger returns. As hunger returns, the tongue clears up, the breath becomes sweet and there is clean taste in mouth. These are all indications that the body has completed the work of cleansing itself and is ready to resume eating. In many instances the results of these short fasts are disappointing. In some instances, the premature breaking is the difference between complete success and partial failure. Certainly health is worth a little added effort. It is possible to break the fast with any food available, but we have found that the safest way in which to break a fast is with juices (freshly squeezed). Dr. Weger, A well known Director of College of Natural Therapeutics in Chicago, USA broke his fast often with a handful of popcorn. His reason for this was that the corn served as a broom to sweep out the digestive tract. 

Conclusions:
Caring for the needs of life to secure health and proper weight maintenance is a constant hygienic responsibility. We all have the health we deserve and no more. There is no such miracle as permanent recovery in the sense that we can become so healthy we need give no further attention to our health. Diet is clearly one of the fundamental to good health, yet just few of us really spend thought or time on designing a diet that will promote health. Far too many people have fallen prey to the comforts of modern life, with its physical inactivity and reliance on foods that provide temporary sensory gratification at the expense of true nourishment. As a result, there is an epidemic of diet-related diseases in the developed and developing countries. Fasting or calorie restriction, once used to be a customary practice in our Indian culture are now getting replaced by corollary rituals like substituting another spectra of food and therefore the effects convened through the spiritual and scientific process of fasting needs another revamp integrating ancient wisdom and modern insights from science.

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*Dr. Mukund Baheti  is Consultant Neurologist, Baheti Hospital, Nagpur. He completed his M.D. (Medicine) and D.M.  (Neurology) from Grant Medical College & J.J. Group of Hospitals, Mumbai. He has 28 years of experience in neurology practice. His special interest is in treatment of EPILEPSY, Migraine, Headache, Stroke. He is interested in prevention of disorders and promotion of health.   He had been invited in various National and International forums for integrating holistic approach in Medicine and Ayurveda. He had received several awards for his "free teaching" to Medical students and private practitioners.

**Dr. Praveen Khairkar is presently working as Professor, Dept of Psychiatry, MGIMS. He loves teaching and his area of research is Neuropsychiatry, Adult Psychiatry, Consultation-Liaison Psychiatry, and Neurobiology. He received his non-invasive brain stimulation intensive training for various neuropsychiatric disorders at Beth Israel Deaconesses Medical Centre affiliated to Harvard Medical School, Boston, USA in 2012-13. He became the youngest fellow of Indian Psychiatric Society, Postgraduate guide and university recognized associate professor in country in 2010. He has worked in collaboration with ICMR, IPS, WHO, USAIDS, WSEAS, Centre of Neuroscience, California, USA, and NIMHANS Bangalore. He has published more than 30 articles in National & International Journals and also serves as reviewer in three prestigious European journals. He was the only Indian in the 10 best scientific paper award acclaimed in 19th European Congress of Psychiatry held in Vienna, Austria in March 2011. .

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