Jamil J, Ali S, Ahmad A, Al-Zakwani M, Gul A, Shah PA, Haq S, Lawitz E. Metabolic profiles and hepatic steatosis assessed by controlled attenuation parameter and elastography during Ramadan fasting in San Antonio, United States. World J Radiol 2026; 18(3): 117162 [DOI: 10.4329/wjr.v18.i3.117162]
Corresponding Author of This Article
Pir A Shah, Department of Medicine, Creighton School of Medicine, 3100 Central Avenue, Phoenix, AZ 85012, United States. pirashah2020@gmail.com
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Radiology, Nuclear Medicine & Medical Imaging
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Prospective Study
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Mar 28, 2026 (publication date) through Mar 26, 2026
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World Journal of Radiology
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Jamil J, Ali S, Ahmad A, Al-Zakwani M, Gul A, Shah PA, Haq S, Lawitz E. Metabolic profiles and hepatic steatosis assessed by controlled attenuation parameter and elastography during Ramadan fasting in San Antonio, United States. World J Radiol 2026; 18(3): 117162 [DOI: 10.4329/wjr.v18.i3.117162]
World J Radiol. Mar 28, 2026; 18(3): 117162 Published online Mar 28, 2026. doi: 10.4329/wjr.v18.i3.117162
Metabolic profiles and hepatic steatosis assessed by controlled attenuation parameter and elastography during Ramadan fasting in San Antonio, United States
Author contributions: Jamil J, Ali S, Ahmad A, Al-Zakwani M, and Shah PA designed the research study; Jamil J, Ali S, Al-Zakwani M, Gul A, Shah PA, and Haq S performed the research; Jamil A, Al-Zakwani M, Ali S, Shah PA, and Lawitz E analyzed and interpreted the data. All authors contributed to the writing and final approval of the manuscript.
Institutional review board statement: This study was conducted in accordance with the principles of the Declaration of Helsinki and was approved by the Institutional Review Board of the University of Texas Health Science Center at San Antonio and the Center for Institutional Review Board Intelligence Platform (approval No. Pro00061668).
Clinical trial registration statement: This study was not registered as a clinical trial, as it did not meet the criteria for mandatory trial registration.
Informed consent statement: All study participants, or their legal guardian, provided informed written consent prior to study enrollment.
Conflict-of-interest statement: All the authors report no relevant conflicts of interest for this article.
CONSORT 2010 statement: The CONSORT 2010 checklist does not apply.
Data sharing statement: The data that support the findings of this study are available from the corresponding author upon reasonable request.
Corresponding author: Pir A Shah, Department of Medicine, Creighton School of Medicine, 3100 Central Avenue, Phoenix, AZ 85012, United States. pirashah2020@gmail.com
Received: December 1, 2025 Revised: December 9, 2025 Accepted: January 15, 2026 Published online: March 28, 2026 Processing time: 116 Days and 11.4 Hours
Abstract
BACKGROUND
Ramadan fasting (RF) is a form of time-restricted feeding, where individuals abstain from eating and drinking from dawn to sunset. RF has been shown to have positive effects on weight loss, as well as vascular and metabolic disorders. We evaluated the effects of RF on the metabolic profiles of a cohort of Muslims in San Antonio. FibroScan (vibration-controlled transient elastography + controlled attenuation parameter) was used to assess liver stiffness and steatosis before and after RF.
AIM
To evaluate the effects of RF on metabolic and liver profiles, including body mass index (BMI), metabolic syndrome (MS), and hepatic steatosis, in a cohort of Muslims residing in San Antonio.
METHODS
A total of 41 subjects residing in San Antonio, TX, who fasted for 14-15 hours daily for 30 consecutive days during Ramadan, were included in this study. Subjects with any alcohol intake, chronic hepatitis (B and C), pregnancy, or use of hepatotoxic/steatotic agents were excluded. All subjects completed two visits (within 1-2 weeks before and after Ramadan). Each visit involved measurements of BMI, blood pressure, metabolic markers (fasting lipid panel and glucose), liver tests [gamma-glutamyl transferase, aspartate aminotransferase, alanine aminotransferase, alkaline phosphatase, bilirubin (total and indirect), albumin], and FibroScan measurements.
RESULTS
Prior to RF, 29% had MS and 37% had BMI ≥ 30. MS was present in 11% with BMI < 30 and 60% with BMI ≥ 30 (P = 0.01). Hepatic steatosis was more prevalent in the BMI ≥ 30 group (66% vs 30%, P = 0.02) and correlated with BMI (r = 0.54, P = 0.0003). Most participants had mild fibrosis (F0-1 or F2), with advanced fibrosis in 8% (BMI < 30) and 14% (BMI ≥ 30). Liver enzymes were largely normal at baseline. After 30 days of RF, body weight and BMI significantly decreased (P < 0.0001), while MS prevalence remained unchanged. Controlled attenuation parameter scores improved significantly overall (278.6 dB/m to 264.4 dB/m, P < 0.0001) and within both BMI groups, with no major changes in glucose, lipids, or aminotransferases.
CONCLUSION
In this South Asian Muslim cohort, MS prevalence was high, especially in males with BMI ≥ 30. Higher BMI correlated with steatosis; 30-day RF reduced weight and improved steatosis.
Core Tip: Ramadan fasting is a culturally significant, time-restricted dietary practice whose effects on hepatic steatosis and metabolic health are not well characterized in South Asian populations especially residing in United States. In this prospective observational study of 41 adults in San Antonio, metabolic profiles, body mass index, and liver parameters were measured before and after 30 days of fasting. Hepatic steatosis was quantified by controlled attenuation parameter and fibrosis by elastography. Fasting led to significant reductions in body weight and controlled attenuation parameter-measured steatosis, regardless of baseline body mass index, highlighting the potential radiologic and metabolic benefits of Ramadan fasting.
Citation: Jamil J, Ali S, Ahmad A, Al-Zakwani M, Gul A, Shah PA, Haq S, Lawitz E. Metabolic profiles and hepatic steatosis assessed by controlled attenuation parameter and elastography during Ramadan fasting in San Antonio, United States. World J Radiol 2026; 18(3): 117162
Time-restricted feeding (TRF) is a weight loss strategy that limits food and drink intake to specific hours of the day. Various forms of intermittent fasting, including TRF, have been shown to positively impact metabolic health and promote weight loss[1]. Ramadan, observed during a specific month of the lunar calendar, requires Muslims to fast from pre-dawn until sunset as a religious obligation. During this period, individuals abstain from eating, drinking, and smoking for 12-18 hours, depending on geographic location[2]. This fasting period provides a unique opportunity to study the metabolic effects of TRF. Studies have suggested that Ramadan fasting (RF) improved metabolic syndrome (MS) and metabolic dysfunction-associated liver disease (MASLD), formerly known non-alcoholic fatty liver disease[3-6]. However, these findings have been inconsistent.
In the Greater San Antonio area, MASLD and metabolic-associated steatohepatitis is reported at 38% and 14% respectively, in the general populations[7]. However, the prevalence of MASLD among Muslims remains unclear. Understanding the effects of RF on liver and metabolic profiles in this population - particularly those with pre-existing MASLD is crucial. We evaluated the effects of RF on metabolic profiles of a cohort of Muslims in San Antonio. FibroScan [vibration-controlled transient elastography + controlled attenuation parameter (CAP)] was used to assess liver stiffness (LSM) and steatosis before and after RF.
MATERIALS AND METHODS
Study subjects
All the participants were enrolled from the El Bari community clinic in San Antonio. Entry criteria for the study included male or female aged from 18 years to 70 years who observed RF in 2022. They must be able to understand and provide informed consent and were willing to follow the study procedures. Exclusion criteria included current or past alcohol use; known chronic liver disease other than MASLD; pregnancy; platelet count < 100 × 109/L; hemoglobin < 11 g/dL; history of cancer; solid organ transplant; or use of medications known to be hepatotoxic, steatotic, or to substantially affect body weight, metabolism, or appetite. These medications included systemic corticosteroids (e.g., prednisone), glucagon-like peptide-1 receptor agonists, sodium-glucose cotransporter 2 inhibitors, insulin, and other agents with significant metabolic or steatogenic effects. Exclusions were assessed during the screening visit through a structured clinical history, comprehensive medication review, and laboratory testing. Less common chronic liver diseases (e.g., autoimmune hepatitis, Wilson’s disease, hemochromatosis) were ruled out based on clinical history and absence of suggestive findings, while more common etiologies such as viral hepatitis were excluded using hepatitis B surface antigen and anti-hepatitis C virus antibody testing with reflex polymerase chain reaction. The study was approved by the Institutional Review Board of the University of Texas Health Sciences San Antonio and the Center for Institutional Review Board Intelligence Platform.
Procedures
All subjects were evaluated at two visits; baseline visit 1-2 weeks before and the second visit within 2 weeks after Ramadan. They were instructed to fast for 12-14 hours before each visit. At the first visit, demographics and medical history were recorded, and anthropometric measurements such as vital signs, body mass index (BMI), and waist and hip circumferences were recorded. Weight and height were measured at baseline without shoes for BMI calculation. Waist and hip circumferences were measured using a non-stretchable tape.
Baseline laboratory tests including complete blood count, urea, creatinine, fasting glucose lipid panel, liver associated enzymes [gamma-glutamyl transferase, aspartate aminotransferase (AST), alanine aminotransferase (ALT), alkaline phosphatase, bilirubin], hepatitis B and C screening. FibroScan measurements were recorded using the vibration-controlled transient elastography and CAP methods. The FibroScan device used was a FibroScan Mini 430 (SN: F92221; Echosens SA, Paris, France) model equipped with both M and XL probes, and the automatic probe selection tool in the device software was used to determine the appropriate probe for each subject. FibroScan measurements were considered successful if at least 10 valid measurements were obtained with an interquartile range/median ratio below 30%, following established guidelines for transient elastography. At second visit, any changes in medication were recorded in addition to repeat anthropometric measurements, fasting glucose lipid panel, complete blood count, liver associated enzymes and FibroScan measurements.
Hepatic steatosis was defined as having a CAP score of 280 dB/m. Hepatic fibrosis staging was based on the following criteria: (1) Stage 0-1: LSM < 7 kPa; (2) Stage 2: LSM 7-10 kPa; (3) Stage 3: LSM > 10-14 kPa; and (4) Stage 4: LSM > 14 kPa. MS was defined according to the Adult Treatment Panel III criteria. Individuals who meet three or more of the following criteria are considered to have MS: Abdominal obesity: A waist circumference of at least 40 inches (102 cm) for men and at least 35 inches (88 cm) for women. Elevated triglycerides: A fasting triglyceride level of at least 150 mg/dL. Reduced high-density lipoprotein (HDL) cholesterol: An HDL cholesterol level of less than 40 mg/dL for men and less than 50 mg/dL for women. Hypertension: A systolic blood pressure of at least 130 mmHg or a diastolic blood pressure of at least 85 mmHg, or if patient has been taking medication(s) for high blood pressure. Elevated fasting glucose: A fasting plasma glucose level of at least 100 mg/dL or if patient has been taking medication(s) for diabetes mellitus.
This study was designed as a prospective pilot observational study conducted over a single RF period. Because the purpose of the study was exploratory, to characterize metabolic and hepatic changes and generate preliminary effect-size estimates for future powered studies, no formal a priori sample size calculation was performed. Enrollment was limited by the fixed study window and strict eligibility criteria, resulting in a final sample of 41 participants.
Statistical analysis
Statistical analysis was performed using Microsoft Excel, with group comparisons being made using T tests, χ2 analysis, and analysis of variance as appropriate. Descriptive statistics were used to summarize the data.
RESULTS
At baseline
A total of 41 subjects were enrolled in this study. Thirty-two (78%) from India, Pakistan, Bangladesh, 4 (10%) from Middle east countries (Iraq, Egypt), and 5 (12%) White Americans. The majority (61%) were male and 84% were younger than 50 years of age. Their baseline clinical characteristics are presented in Table 1. Prior to RF, 12 (29%) of the subjects had MS and 15 (37%) had BMI ≥ 30. Among the 26 subjects with a BMI < 30, 3 (2 males and 1 female; 11%) had MS. In contrast, among the 15 subjects with a BMI ≥ 30, 9 (7 males and 2 females; 60%) had MS (P = 0.01). Similarly, the prevalence of hepatic steatosis was higher for those with BMI ≥ 30 (66%) compared to those with BMI < 30 (30%, P = 0.02). There was a significant correlation between hepatic steatosis and BMI at baseline (correlation coefficient: r = 0.54, P = 0.0003) (Figure 1). At baseline, the majority had minimal F0-1 (83%) or moderate F2 (12%) hepatic fibrosis. Advanced F3-4 fibrosis, however, already present in 8% and 14% of the subjects with BMI < 30 and ≥ 30 respectively. Of 5 (12.2%) and 8 (19.5%) had AST and ALT elevations at baseline respectively. Only 2 (4%) subjects had abnormal alkaline phosphatase. The cohort had mean total bilirubin of 0.3 mg/dL (0.2-1.1) and platelet count of 293 K/μL (185-462).
The changes in metabolic and FibroScan profiles in the cohort were presented in Table 2. There is a significant reduction in body weight and BMI after 30 days of RF (P < 0.0001). The proportion of subjects with MS post RF was no different from baseline. While the fasting glucose and lipid profile were similar, the hepatic steatosis improved after RF. Namely, the mean FibroScan CAP score decreased from 278.6 dB/m to 264.4 dB/m (P < 0.0001). While there was a significant reduction in alkaline phosphatase levels (P = 0.01), there was no change in other serum aminotransferases or liver function tests.
Table 2 Pre-Ramadan and post-Ramadan metabolic profiles and FibroScan values, median (interquartile range).
Post RF results for baseline BMI < 30 and BMI ≥ 30
For both subjects with baseline BMI < 30 and ≥ 30, there was a significant reduction in weight after RF (Figure 2A). A reduction of 3 lbs and 5 lbs on average were observed among those with BMI < 30 and ≥ 30 respectively. Similarly, there was a significant reduction in CAP scores after RF among subjects with baseline BMI < 30 [262 (100-337) dB/m vs 254.6 (170-369) dB/m, P = 0.04] and BMI ≥ 30 [307 (203-399) dB/m vs 281 (100-387) dB/m, P = 0.01] respectively (Figure 2B). There was a significant reduction in fibrosis scores for subjects with BMI < 30 [5.4 (2.9-10.9) kPa vs 4.4 (2.4-11.2) kPa, P < 0.001]. Among those with BMI ≥ 30, there was no significant change in the mean fibrosis scores (P = 0.06) (Table 3). The proportion of subjects with advanced stage 3-4 fibrosis decreased post RF in both groups: Namely, a 4% and 6% reduction for those with BMI < 30 and ≥ 30 respectively. For those with BMI < 30, improvement in systolic and diastolic pressure were observed after RF. Only improvement in diastolic pressure was noted for those with BMI ≥ 30. There was no change in fasting triglyceride or glucose levels for both BMI groups. Reduction in low-density lipoprotein levels was noted only in the BMI < 30 group (P = 0.02). AST levels did not decrease in the BMI < 30 group (P = 0.09), but had a significant decline in the BMI ≥ 30 group (P = 0.006) post RF. ALT and gamma-glutamyl transferase levels did not show significant changes for either group while alkaline phosphatase decreased in both (Table 3).
Figure 2 Post Ramadan fasting changes in both body mass index < 30 and ≥ 30 cohorts.
A: Both body mass index < 30 and ≥ 30 cohorts had weight reduction with Ramadan fasting; B: Both body mass index < 30 and ≥ 30 cohorts had steatosis reduction with Ramadan fasting. CAP: Controlled attenuation parameter; BMI: Body mass index.
Table 3 Pre-Ramadan and post-Ramadan profiles associated with baseline body mass index, median (interquartile range).
MASLD has become the most common cause of chronic liver disease worldwide, with a global prevalence of approximately 30%[8]. This trend is particularly pronounced in South Asian communities, where studies indicate that the prevalence of MASLD has risen due to increasing obesity and sedentary lifestyles. In some South Asian populations, the prevalence of MASLD has reached as high as 65.7%[9]. MASLD can lead to advanced fibrosis, hepatocellular carcinoma, and complications related to cirrhosis and portal hypertension[10]. Liver biopsy is the gold standard for diagnosing MASLD but is invasive and carries risks such as pain and bleeding[11]. Transient elastography is proven to be a reliable and noninvasive method to evaluate hepatic steatosis and fibrosis with a specificity and sensitivity ranging between 81.6%-86.6% and 71.6%-80.9% respectively[12]. Our study used transient elastography, FibroScan, as well as metabolic parameters to investigate the impact of RF in the San Antonio community.
In our predominantly South Asian cohort, approximately 30% had MS and a BMI > 30 at baseline. The prevalence of MASLD, as assessed by FibroScan, was notably high at 44%. Hepatic steatosis was present in 30% and 66% of those with BMI < 30 and ≥ 30 at baseline before RF. While the majority (> 80%) had minimal F0-1 hepatic fibrosis, advanced F3-4 fibrosis was evident in 8% and 14% of the subjects with BMI < 30 and ≥ 30 respectively. These findings underscore the importance to systematically evaluate South Asians for MASLD. There are limited studies focus on the effect of RF on MASLD. Arabi et al[13] observed 50 patients with MASLD and reported a decrease in ALT level and blood pressure associated with RF. A recent study in Egypt by Gad et al[14] noted significant improvement in hepatic steatosis and fibrosis with RF.
Our study found a significant reduction in body weight and BMI after 30 days of RF, regardless of the baseline obesity status. On average, participants lost between 1.8% to 2.3% (1.4 kg to 2.2 kg) of body weight and experienced a BMI reduction between 0.4 kg/m2 and 1.0 kg/m2. Similar results were reported in a meta-analysis by Al-Jafar et al[15] in 2023; they found an average weight loss of 1.12 kg and a decrease of 0.74 kg/m2 in BMI after 30 days of fasting among 66 healthy individuals. Gad et al[14] observed a significant decrease in BMI in participants with MASLD during Ramadan, while Furuncuoğlu et al[16] reported no significant changes in weight or BMI after 30 days of fasting. These discrepancies may stem from variations in food consumption and physical activity levels after breaking the fast during Ramadan[17]. To better understand the impact of RF on weight and BMI, it is important to quantify the number of calories consumed after breaking the fast and the amount of physical activity during the fasting period.
The overall prevalence of steatosis in our study population was 44% at baseline. Gad et al[14] investigated the effects of RF in a population with MASLD and observed a pronounced reduction in CAP scores after 30 days (318.5 dB/m to 294.0 dB/m; P < 0.001). In a 12-week controlled study of RF in MASLD patients, Hodge et al[18] demonstrated a significant reduction in CAP score for those who fasted (287 dB/m to 263 dB/m; P = 0.012), but failed to observe a similar reduction in the non-fasting control group (268 dB/m to 268 dB/m; P = 0.981). We demonstrated a significant correlation between body weight and steatosis score. Weight loss most likely contributed to the reduction in CAP scores. Promrat et al[19] reported greater improvement in steatosis among participants who lost at least 7% of their body weight in a 48-week study focusing on individuals with metabolic-associated steatohepatitis. Behari et al[20] reported that a mean weight loss of 13.4% was associated with a reduction in CAP score. Although our participants did not achieve weight loss close to the levels reported in these longer-term follow-up studies, the weight loss achieved during the 4-week fasting period still correlated with a statistically significant drop in CAP scores. Future studies could benefit from monitoring weight loss achieved through fasting over a longer period to observe the associated changes in hepatic steatosis.
Although we did not observe a significant reduction in hepatic stiffness in individuals with BMI ≥ 30, we did find a decrease in the proportion of subjects with advanced stage 3-4 fibrosis following RF. The study conducted by Gad et al[14] showed a more significant improvement in LSM following 30 days of RF (6.95 kPa to 6.59 kPa; P < 0.001). The difference is likely related to the study populations. Gad et al[14] only included participants with MASLD at baseline. In our study, only 18 out of 41 (44%) participants had MASLD. Participants with established MASLD had a higher baseline LSM score and had more room for improvement compared to the majority of our participants who did not have an elevated stiffness at baseline.
A 2021 meta-analysis[21] of 601 healthy adults found a significant (albeit small) reduction in liver transaminases (AST and alkaline phosphatase) following RF. In our study, we observed modest changes in liver enzymes within our cohort. AST levels decreased significantly in the BMI ≥ 30 group, while ALT remained unchanged. This discrepancy may be due to AST’s greater sensitivity to short-term metabolic changes, whereas ALT typically reflects longer-term hepatocellular injury, which may not be significantly influenced by a 30-day fasting period. With rare exception[22], our finding is consistent with other studies on healthy[21] or MASLD populations that only a small improvement in liver tests was observed[14,23,24]. These changes were not clinically significant, as most of our participants had normal liver enzyme values at baseline. Rahimi et al[22] showed that ALT levels actually increased in fasting individuals with MASLD as opposed to non-fasting individuals. Variability in dietary practices during fasting in different cultures may explain these discrepancies. Studies have shown fasting individuals who consume diets high in fat, sugar and total carbohydrates in the hours after breaking their fast tend to have less improvements in liver enzymes[21].
Our study observed slight or no improvement in lipid profile after 30 days of fasting that was consistent with previous studies[24-26], reporting either no or modest improvement in HDL and/or triglyceride levels after the same duration. However, Gad et al[14] found improvement in HDL and other lipid profile after 30 days of fasting among healthy adult subjects and MASLD patients. Gad et al[14] primarily studied Egyptians, while our study subjects were mostly from South Asia. Studies have shown that differences in dietary practices can affect lipid panel levels[14,27].
The literature on fasting in diabetic and/or prediabetic patients is conflicting. One study reported worsening glycemic control following fasting[28]. while several others have demonstrated significantly improved hemoglobin A1c levels[14,23]. Baseline glycemic control may explain differences in study outcomes. For example, M'guil et al[29] found no change in glycemic control with RF among those well glycemic controlled participants. Memel et al[30] have noted that meals consumed during the Ramadan holiday tend to be high in sugar and/or fat, which likely confound the results. In our study, no conclusion can be made on glycemic control as our population was composed of patients with normal glycemic indices at baseline. We acknowledge that the overall sample size, and particularly the BMI ≥ 30 subgroup, was modest. As this was an exploratory pilot study conducted over a single RF period, recruitment was constrained by the study window and strict eligibility criteria. Accordingly, subgroup analyses, especially for individuals with BMI ≥ 30, should be interpreted with caution due to limited statistical power. Nevertheless, the consistent directionality and statistical significance of several observed changes support the biological plausibility of our findings and provide important preliminary data to guide future adequately powered studies.
This study highlights the potential benefits of RF for weight reduction and hepatic steatosis, but its findings must be viewed in the context of several limitations. As an exploratory pilot study with a modest sample size-particularly among those with BMI ≥ 30, the results may not be generalizable to larger, more diverse populations. Moreover, since the study was conducted over a single RF period, the long-term effects of RF on metabolic health and liver function remain unclear. Future research should focus on larger, well-powered studies with extended follow-up periods to better understand the sustained impact of RF. Furthermore, detailed assessments of dietary intake and physical activity during non-fasting hours are needed to clarify their role in the observed outcomes. Such investigations will be crucial in establishing the broader applicability of RF as a therapeutic approach for MS and liver diseases.
CONCLUSION
This study demonstrates that RF, as a form of TRF, is associated with weight reduction and improvements in hepatic steatosis in a cohort of Muslims from the San Antonio area, regardless of baseline BMI. While the overall metabolic profile showed minimal changes, there was a significant reduction in LSM in subjects with lower BMI, and a modest improvement in liver function markers, particularly alkaline phosphatase. These findings suggest that RF could be an effective strategy for managing metabolic dysfunction and hepatic steatosis, particularly in South Asian populations, who are at higher risk for MASLD. Although the study did not observe significant changes in all metabolic parameters, such as fasting glucose and lipid profiles, it provides valuable preliminary data that supports the potential of RF as a weight loss intervention and its effects on liver health. Future studies with larger sample sizes and longer follow-up periods are needed to further explore the long-term impact of RF on liver fibrosis, metabolic health, and the role of dietary intake and physical activity during the fasting period. These findings highlight the importance of further research to refine dietary strategies during fasting periods to maximize the health benefits of TRF.
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